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Fellowships 

for 

HMS Alumni 



Fellowships are available for graduates of Harvard Medical School 
to undertake a year of post-graduate study. The amounts awarded for 
stipends are determined by the specific needs of the individual. 

Moseley Traveling Fellowship 

Support for at least a year of postgraduate study in Europe. 

The Committee on Alumni/ae Fellowships gives preference to those 

Harvard Medical School graduates who have: 

1 

demonstrated their ability to make original and meritorious contributions 

to knowledge, 

2 

planned an innovative program of study which in the Committee's opinion 

will contribute significantly to their development as teachers and scholars, 

3 

clearly planned to devote themselves to careers in academic medicine 

and the medical sciences. 

Warren-Whitman-Richardson 

Support for research in the U.S. or abroad; not restricted to alumni. 
Directed to M.D. scientists who require further training. 

Deadline 

Although there is no specific due date, the Committee requests that 
applications be submitted not more than one year in advance of the 
requested beginning date. The Committee meets once a year in January 
to review all applications on file by December 31 . 

Information and application forms may be obtained from: 

Committee on Alumni/ae Fellowships 

c/o Sponsored Programs Administration 

Harvard Medical School 

Room 414, Building A 

25 Shattuck Street 

Boston, Massachusetts 021 15 

617/432-1596 



Summer 1995 
Volume 6^ Number i 



Harvard Medical 



ALUMNI 



BULLETIN 




Marbleized paper by Richard J. 
Wolfe, who practices the tradi- 
tional craft of marbling used in 
the book arts to embellish 
hand book-binding. Ghosted 
images are of Herrman 
Blumgart, Alfred Reinhart and 
William Lambert Richardson. 



12 Diary of a Fatal Illness 

by Burton I. Korelitz 

The student chronicles of a now 

curable heart disease. 

21 Transplantation 

by Francis D. Moore 
Early events in the history of organ 
transplantation excerpted from his 
just published autobiography, 
A Miracle & a Privileae. 

Murray's Medal 

by Ten-i L. Rutter 

28 The Deliverer 

by James Locke Neller 

A 1930s introduction to the 

"wonders and mysteries" of 

obstetrics. 

34 The Old Chief 

by Frederick C. Irving 
Excerpt from Safe Deliveraiice, in 
which the legendary chief-of-staff 
of Boston Lying-in depicts one of 
the earlier legends, William 
Lambert Richardson. 



42 Serendipity and the Career of 
Herrman Blumgart 

by Franklin H. Epstein 
Remembering the man who, until 
his retirement in 1962, was the most 
influential person at Boston's Beth 
Israel Hospital. 

50 The Physician-Scientist: Dual or Dueling 
Degrees? 

by David A. Shaywitz 

Is the MD/phD an "elegant synthesis 

of two passions" or an unrealistic 

ideal? 

57 Seventh Shift 

by Charles C. Hartness 
A short story. 



Departments 

3 Letters 

4 Pulse 

Third NOVA installment, mental 
illness in the Third World, 
Galaburda named Landau Professor, 
teenage smoking, match day. 



37 For Better or For Worse 

by Thomas H. Coleman 

A forbidden marriage comes to the 

attention of Harvey Gushing. 

38 Countway's Biographical Sleuths 

by Ellen Barlow 

And their never-ending source of 

histories waiting to be written. 



11 On the Quadrangle 

A new academic track estabhshed for 
the clinician scholar. 

58 Alumni Notes 

62 in Memoriam 

Ashton Graybiel 

64 Death Notices 



Letters 



Pulse 



up wath a reasonable cost accounting 
to justify a career of two or three 
decades? As with so many other prob- 
lems, the government will be asked to 
underwrite the costs of medical educa- 
tion in the 2 ist century. Our govern- 
ment has never been too prescient in 
cost accounting or quality control, but 
when in control of the medical educa- 
tion purse, it will demand complete 
control of both the process and the 
product. 

The disproportion and distortions 
of the current medical school admis- 
sions policy must inevitably displace 
equally or better qualified white male 
students from Harvard Medical 
School. Those of us who may disagree 
with current admission policy can do 
little to reverse the trend, but we can 
cease to contribute to the unrestricted 
funds that help underwrite that policy. 

Johi M. Carey 45 



Residency on View 

Harvard Medical School students from 
the Class of 199 1, who were docu- 
mented by NOVA as they went through 
medical school, have now completed 
internship for all the country to view 
on PBS. Aired on May 3, this is the 
third of a four-part series called 
"Making of a Doctor," a lo-year pro- 
ject chronicling medical education 
through residency. 

Viewers follow the seven new doc- 
tors — Elliot Bennett-Guerrero, Jay 
Bonnar, Cheryl Dorsey, Luanda 
Grazette, David Friedman, Jane 
Liebschutz and Tom Tartar — from 
their first fearful days on the job 
through the jubilant finish of the first 
year. The strains of internship take a 
toll: two marriages are broken along 
the way and exhaustion causes at least 
one of them to question the person he 
is becoming when he says, "all I want 
to do is get out [and sleep]." 



But you do see their confidence 
growing and there are some heart- 
warming scenes as they more comfort- 
ably relate not always comforting news 
to patients and the families. By the end 
of internship, they really feel like doc- 
tors: "Dr. Liebschutz, it has a nice 
ring," says Jane Liebschutz. 

It's time to move on to the rest of 
residency — "The fat lady has sung," 
says Grazette at her farewell party at 
Massachusetts General Hospital. The 
credits roll and we see flashbacks from 
their second-year show, the front of 
Building A. . . to be continued. 



David Friedman Is one of the HIVIS graduates being followed by NOVA. 




Harvard Medical Alumni Bulletin 



Mental Illness in the Third World 

While public health measures have 
resulted in a decrease in diseases such 
as smallpox and dysentary in the devel- 
oping world, an unfortunate conse- 
quence has been an alarming rise in 
serious mental illness among the popu- 
lations of the world's poorest nations, 
says a recent report published by the 
HMS Department of Social Medicine. 
As people's hfe expectancy increases, 
so does their risk of developing 
chronic mental illness. 

"There is an emerging and largely 
unheralded crisis in mental, behavior- 
ial and social health in low-income 
countries," says Arthur Kleinman, 
Maude and LiUian Presley Professor of 
Medical Anthropology and head of the 
department. 

The report, which was based on 
research by 88 specialists from 30 
nations, found that Sri Lanka has the 
highest suicide rate in the world, 
nearly four times that of the United 



States; children in Malaysia, 
Bangladesh and Pakistan suffer mental 
retardation at rates two to three times 
higher than children in industrialized 
nations; estimated cases of schizophre- 
nia are expected to rise to 24.4 million 
by the end of the century; and by 
2025, the developing world will house 
three-quarters of the world's cases of 
dementia. 

The outbreak of regional conflicts 
and civil wars from Rwanda to 
Guatemala has caused a massive influx 
of refugees — two-thirds of whom suf- 
fer from post-traumatic stress disorder 
and related conditions such as anxiety, 
depression and stress. "These displace- 
ments can destabilize the host country, 
aggravate regional tensions, and 
increase rates of environmental degra- 
dation," says the report. 

The report calls on international 
health agencies to support existing 
community-based programs to inte- 
grate psychiatric care into primary 



health care delivery systems, including 
in some cases the use of traditional 
healers and rituals. It also recommends 
training mental health workers and 
developing efforts to assess the inter- 
national burden of drugs and alcohol. 
It calls for a world summit and the 
declaration of a UN Year of Mental 
Health. 

The report was presented to 
United Nations Secretary General 
Boutros Boutros-Ghali, who released a 
statement calling for an "international 
campaign" to address the issues. 



Veena Das, who con- 
tributed to the report, 
and Arthur Kleinman. 




Summer 1995 



Pulse 



Galaburda Named Landau Professor 

Albert Galaburda, head of the division 
of beha\aoral neurology at Beth Israel 
Hospital, has been named the first 
Emily Landau Professor of Neurology. 
Emily Landau, a philanthropist who 
was diagnosed with dyslexia in her 
mid-50s, established the professorship 
to further the study of this disability, 
which affects approximately 5 percent 
of school-age children nationwide. 

Galaburda, a leading authority on 
brain anatomy and one of a very few 
medical researchers to champion the 
study of dyslexia, has discovered 
microscopic anomalies in the cerebral 
cortex of those with the disorder. In 
studies on the brains of dyslexics, col- 
lected after the subjects had died, 
researchers in Galaburda's lab found 
that the neurons clumped together in 
an area called the medial geniculate 
nucleus (mgn) were smaller in the 
dyslexics' brains than those found in 
normal brains. The MGN is where 



auditory signals are directed through- 
out the brain; the size differential sug- 
gests that a mistiming may occur in 
dyslexics, which affects how words are 
processed. 

"We are learning that genetic and 
environmental factors that influence 
brain development play a critical role 
in dyslexia," he says. "[This professor- 
ship] supports the efforts to carry out 
brain research aiming at a more thor- 
ough understanding of dyslexia and, 
eventually, a more effective means of 
preventing and treating dyslexia." 

Landau, who struggled throughout 
her youth and young adulthood with 
the learning difficulties caused by the 
disorder without understanding why, 
established the Fisher Landau 
Foundation in 1 984 to raise awareness 
of dyslexia and to identify children at 
risk. Her efforts led to the develop- 
ment of the Fisher Landau Screening, 
which identifies learning disorders in 
children as young as four and five 



years old. 

She and Galaburda have worked 
together to develop a series of confer- 
ences entitled "The Extraordinary 
Brain," dedicated to exploring the dif- 
ferent aspects of dyslexia and inspiring 
the attending scientists, who come 
from fields ranging from genetics to 
language development and brain imag- 
ing, to pursue research in this area. 




Emily Landau and Albert 
Galaburda 



Harvard Medical Alumni Bulletin 




David Kessler 



Kessler Decries Teenage Smoking 

"It's easy to think of cigarette smoking 
as an adult problem since that's who 
dies from smoking," said David 
Kessler '79, commissioner of the U.S. 
Food and Drug Administration. "But 
that is a dangerously short-sighted 
view." Kessler spoke on nicotine 
addiction as a "pediatric disease" at a 
HMS lecture in honor of the late 
Norman Zinberg, a professor of psy- 
chiatry who specialized in addiction 
research. 

"If someone hasn't started smoking 
by age 19 to 2 1, he or she isn't likely to 
ever become a smoker," Kessler 
pointed out. One-third to one-half of 
teenagers who try even a few cigarettes 
will become regular smokers. Every 
day 3,000 teens take up smoking. 

The tobacco companies target 
teenagers with their advertising cam- 
paigns because they know this, said 
Kessler. To make smoking seem glam- 
orous, advertising is linked to the 
world of sports and entertainment. 
Tobacco companies also have devel- 
oped chewing tobacco products that 
"taste like candy," according to 
Kessler, and have low levels of nicotine 
as "starter kits" to nicotine addiction. 

The FDA is currently deliberating 
whether it has jurisdiction over nico- 
tine as a drug, and thus could more 
stringently regulate access to tobacco 
products. At the very least, Kessler 
argued, "Our society needs to make it 
harder for teens to buy cigarettes" and J 
to convey the message that "addiction g 
is freedom denied." iS 



Tiie Match is Made 

It was another "amazing" year for HMS 
students with most matching to the 
top programs they wanted, according 
to Edward Hundert '84, associate dean 
for student affairs. 

Eollowing a national trend, an 
increasing number of graduates are 
heading for the primary care special- 
ties; 50 percent of the Class of 1995 
are going into family practice, internal 
medicine, medicine/pediatrics, pedi- 
atrics or primary care. "It is particu- 
larly interesting that we have four 
people going into family medicine 
since we don't have a department or 
residency in that specialty," says 
Hundert. But he points out that there 
are family medicine clubs and mentors 
on the faculty, so he anticipates that 
interest in it will increase. 

The graduates and their intended 
specialties are: 



ANESTHESIA 

Haddad, Tania 

Massachusetts General Hospital 

Salinas, Ricardo 
Massachusetts General Hospital 

DERMATOLOGY 

Lockridge, Jason 

University of Florida, Shands Hospital 

EMERGENCY MEDICINE 

Aponte, Jennifer 

University of Cincinnati Hospital 

Slater, Michael 

McGaw Medical Center, NW University, Illinois 

FAMILY MEDICINE 

Antenucci, Christina 

Swedish Medical Center, Washington 

Bromer, Steven 

University of California, San Francisco 

Hatcher, Peter 

Oregon Health Sciences University 

MacDonald, James 

Maine-Darthmouth Family Practice, Augusta 




Summer 1995 



Pulse 



Morden, Nancy 

Duluth Graduate Medical Education 



Chittenden, Eva 

Beth Israel Hospital, Boston 



Gillette, Michael 
Massachusetts General Hospital 



Paley, Jeffrey 

Massachusetts General Hospital 



Nunez, Felix 

Harbor-UCLA Medical Center 



Dick, Sarah 

University of Washington Affiliated 



Gold, Alexander 

Beth Israel Hospital, Boston 



Povsic, Thomas 

Duke University Medical Center 



Twardon, Elizabeth 

St. Paul/Ramsey Medical Center 



Domchek, Susan 
Massachusetts General Hospital 



Ho, Carolyn 

Brigham and Women's , Boston 



Raman, Chitra 

University of Chicago Hospital 



INTERNAL MEDICINE 

Abraczinskas, Diane 

Hospital of the University of Pennsylvania 

Albers, Mark 

Massachusetts General Hospital 

Brewster, Abena 
Johns Hopkins Hospital 

Buynak, Robert 

Mayo Graduate School of Medicine, 

Minnesota 



Dunleavy, Katherine 
Johns Hopkins Hospital 

Dunleavy, Keith 
Johns Hopkins Hospital 

Fairfield, Wesley 
Massachusetts General Hospital 

Fischbach, Neal 

University of California, San Francisco 

Foster, David 

Beth Israel Hospital, Boston 



Hsu, Ricky 

UCLA Medical Center 

Hung, Albert 

Brigham and Women's, Boston 

Johannsen, Eric 

Brigham and Women's, Boston 

Karson, Andrew 

Brigham and Women's, Boston 

Kim, Hans 

Beth Israel Hospital, Boston 



Roberts, David 

Massachusetts General Hospital 

Rubenstein, Mark 
Massachusetts General Hospital 

Sabatine, Marc 
Massachusetts General Hospital 

Saito, Yoriko 

Brigham and Women's, Boston 

Sakoulas, George 

New England Deaconess 



Calvi, Laura 

Massachusetts General Hospital 



Fraenkel, Paula Goodman 
New England Medical Center 



Ko, Ed 

Cedars-Sinai Medical Center, Los Angeles 



Shaw, Stanley 

Massachusetts General Hospital 



Cappola, Thomas 

Brigham and Women's, Boston 



Frankel, Stephen 

Beth Israel Hospital, Boston 



Maviglia, Saverio 

Brigham and Women's, Boston 



Shiipak, Michael 

University of California, San Francisco 



Cardinale, Carol 

Presbyterian Hospital, New York 



Gates, Amy 

University of California, San Francisco 



McHugh, Kathleen 

Brigham and Women's, Boston 



Spratt, Susan 

Beth Israel Hospital, Boston 




Trob, Joshua 

Barnes Hospital, St. Louis 

Viramontes, Blanca 

Mayo Graduate School of Medicine, 

Minnesota 

MEDICINE/PEDIATRICS 

Cell, Ann 

Massachusetts General Hospital 

Cheng, Paul 

Massachusetts General Hospital 

Cineas, Sybil 

Massachusetts General Hospital 

Nigrovic, Peter 
Massachusetts General Hospital 

Reilly, Andrea 

Mt. Sinai Hospital, New York 

NEUROLOGY 

Shepherd, Gordon 
Massachusetts General Hospital 



Harvard Medical Alumni Bulletin 




NEUROSURGERY 

Johnson, Mark 

University of Wasliington, Seattle 

Munslii, Hidayatullali 

University of Minnesota, Minneapolis 

Villavicencio, Alan 
Duke University 

Yanez, Paulino 

Mayo Clinic, Minnesota 

OB/GYN 

Atllano, Lorraine 

Brigham and Women's, Boston 

Banerjee, Rini 

Brigham and Women's, Boston 

Caughey, Aaron 

Brigham and Women's, Boston 

Dojaquez, Katherine 

University of New Mexico School of 

Medicine 

Jennings, Chasity 

White Memorial Medical Center, 

Los Angeles 

McHugh, John 

Unwersity of California, San Francisco 

Rainford, Monique 
Georgetown University Hospital 



Sinnock, Kristin 

Beth Israel Hospital, Boston 

Wong, Suzanne 

Brigham and Women's, Boston 

Yen, Janie 

Harbor-UCLA Medical Center 

OPHTHALMOLOGY 

Horn, Erich 

California Pacific, San Francisco 

Hsu, Julia 

Manhattan Eye, Ear & Throat 

Lit, Eugene 
Massachusetts Eye and Ear 

Pollack, Aryeh 

Mt. Sinai Hospital, New York 

Richardson, David 

University of Southern California, 

Los Angeles 

Shivaram, Sunil 

University of Southern California, 

Los Angeles 

Wald, Heidi 

Wills Eye Hospital, Philadelphia 

Zhang, Kang 

Wilmer Institute, Baltimore 



ORAL SURGERY 

Glllardetti, Robert 
Massachusetts General Hospital 

Mason, Sandra 
Massachusetts General Hospital 

ORTHOPEDIC SURGERY 

Battle, Melanie 
Johns Hopkins Hospital 

Deshmukh, Asvin 

Harvard Combined Orthopedic Program 

Faryniarz, Deborah 
Hospital for Special Surgery 

Grayzel, Jonathan 

University of Massachusetts Program 

Harriot, Paul 

Vanderbilt University Medical Center 

Miller, Bruce 

Harvard Combined Orthopedic Program 

Patterson, John 

Harvard Combined Orthopedic Program 

OTOLARYNGOLOGY 

Hilinski, John 

University of California, San Diego 

Nasseri, Shawn 

Mayo Clinic, Minnesota 

Ralph, Walter 

Duke University Medical Center 

Taylor, Rodney 
University of Michigan 

Wang, Steven 
UCLA Medical Center 

PATHOLOGY 

Chow, Yung 

UCU Medical Center 

PEDIATRICS 

Cell, Ann 

Massachusetts General Hospital 

Cheng, Paul 

Massachusetts General Hospital 

Cohen, Gail 

Medical College of Virginia 



Collins, Felicia 
Children's Hospital, Boston 

Downes, Sandra 
Children's Hospital, Boston 

Hirschhorn, Joel 
Children's Hospital, Boston 

Joseph, Jocelyn 
Children's Hospital, Boston 

Lesperance, Leann 
Children's Hospital, Boston 

Livingston, Nina 

University of Washington Affiliated 

Nadeau, Kari 

Children's Hospital, Boston 

Nigrovic, Peter 
Massachusetts General Hospital 

Palomino, Rossana 

Baylor College of Medicine, Houston 

Reilly, Andrea 

Massachusetts General Hospital 

Rein, Jeffrey 

Mt. Sinai Hospital, New York 

Shanahan, Theresa 

New England Medical Center 

Waskow, Shoshana 

Children's Memorial Hospital, Illinois 

Wood, Sarah 

Children's Hospital, Boston 

PLASTIC SURGERY 

Fogaca, Marcelo 
UCLA Medical Center 

Manchester, Kerth 

University of Texas SW Medical School 

Posner, Marc 

University of Chicago Hospital 

PRELIMINARY MEDICINE 

Sawhney, Roger 

Beth Israel Hospital, Boston 

PRELIMINARY SURGERY 

Helman, David 

Massachusetts General Hospital 



Summer 1995 



Pulse 



PRIMARY CARE 

Chung, Wayne 

Mt. Auburn Hospital, Cambridge 

Eakin, Marion 

Mt. Auburn Hospital, Cambridge 

Finn, Katlileen 

Brigliam and Women's, Boston 

Hauser, Josliua 

Brigliam and Women's, Boston 

Lee, Frederick 

Brigham and Women's, Boston 

Levine, Elizabeth 
Rhode Island Hospital 

Olivares, Michael 

Baylor College of Medicine, Houston 

PSYCHIATRY 

Chuang, Kenneth 

UCLA Neuropsychiatric Institute 

Cohen, Sherry 

Medical College of Virginia 

Gomberg, Richard 

Cambridge Hospital, Massachusetts 

Kirby, Janet 

Longwood Program, Boston 

Mazzoni, Pietro 

Presbyterian Hospital, New York 

Meyer, Christopher 

Cambridge Hospital, Massachusetts 

RADIOLOGY 

Doty, David 

New England Deaconess 

Kundra, Vikas 

Brigham and Women's, Boston 

Lee, ChenWei 

Massachusetts General Hospital 

Leung, Gordon 

Massachusetts General Hospital 

Martinez, Camilo 
UCLA Medical Center 



Schlakman, Jonathan 
Massachusetts General Hospital 

SURGERY 

Gawande, AtuI 

Brigham and Women's, Boston 

Hirmand, Mohammad 

Emory University School of Medicine 

Howard, Marissa 

Emory University School of Medicine 

Hutter, Matthew 
Massachusetts General Hospital 

Kosowsky, Jeffrey 
New England Deaconess 

Lee, Richard 

Massachusetts General Hospital 

Lin, Richard 

University of California, San Francisco 

Schwarze, Margaret 
Massachusetts General Hospital 

Tolls, Geoi|;e 

Massachusetts General Hospital 

Wolfe, Roger 

University of Chicago Hospital 

Yen, Tina 

University of Washington Affiliated 

UROLOGY 

Chan, David 

Brady Urological Institute, Baltimore 

Mitchell, Michael 
Harvard Medical School 

Niknejad, Kathy 
Harvard Medical School 

Raut, Chanrajit 
Massachusetts General Hospital 

OTHER 

Callahan, Tamara 
Public Service Fellowship 
Echoing Green Foundation 

Costenbader, Karen 
Research Fellowship, Paris 




Lin, Herbert 

Research Fellowship, Massachusetts 

General Hospital 

Rosario, Vernon 

Research Fellowship, Humanities 
Research Institute, 
University of California, Irvine 



Cunningham, Miles 

Medical Portfolio Management, 

Cambridge 

Ito, Keita 

Research Fellowship, AO/ASIF Research 

Institute, Switzerland 



John Schott, M.D. 

HMS '66 

Investment Advisor 

Managed accounts, 

retirement accounts, 

family trusts 

Dr. Schott provides highly 

personalized investment 

management to individuals, 

families and institutions 

His unique approach and 

established record merit your 

consideration 

Schott Investment 
Corporation 

Publisher of We Schott Letter 

120 Centre Street 

Dover, MA 02030 

(508) 785-9996 

Registered Investment Advisor 

SEC and Commonwealth of 

Massachusetts 



Harvard Medical Alumni Bulletin 



On the Quadrangle 



New Academic Track for Clinician Scliolars 

Three great physicians, who practiced 
in the 1950s and 1960s — Paul Dudley 
White, Samuel Levine and Claude 
Welsh — created a supreme standard 
for the practice of medicine at Harvard 
Medical School and its affiliated hospi- 
tals. They held part-time faculty 
appointments as clinical professors of 
medicine. In order to recognize and 
reward the next generation of great 
clinicians — those who, as David 
Nathan '55, Robert A Stranahan 
Professor of Pediatrics, says, 
"approach" or "equal" the standard of 
these three and who practice full time 
in an HMS-affiliated hospital — the 
school has established a fourth profes- 
sorial track: the clinician scholar. 

"The major focus of the clinician 
scholar ladder," says Mary Clark, asso- 
ciate dean for faculty affairs in the fac- 
ulty of medicine, is to recognize the 
clinicians who are "the ultimate role 
model for the students; those who all 
people recognize as the best doctor, 
the 'doctor's doctor'." 

The clinician scholar track, which 
was formally adopted in March of this 
year, becomes the fourth academic 
track at the school, alongside labora- 
tory investigator, clinical investigator, 
and teacher clinician, which was estab- 
lished in 1989. Unlike the two investi- 
gator tracks, the emphasis in the 
clinician scholar track will not be to 
produce new knowledge, but to perfect 
and maintain one's own clinical skills 
and to impart that knowledge onto 
students, residents and fellows. The 
new track, says Clark, will allow the 
school to recognize "the scholarship of 
transmission as well as the scholarship 
of discovery." 

The fundamental mission of the 
hospitals is caring for patients and 
good clinicians are an integral factor in 
that pursuit. With hospital mergers 
and the advent of clinical care net- 



works, the responsibility to maintain 
Harvard Medical School's preemi- 
nence not just in medical research, but 
also in patient care, needed to be 
reconfirmed. Thus, the desire to keep 
excellent full-time clinicians on staff 
prompted Nathan to discuss the idea 
of a new track with colleagues Robert 
Glickman '64, Eugene Braunwald, 
John Potts, Gerald Austen '55 and 
William Silen. A proposal was then 
made to Dean Daniel Tosteson '49, 
who appointed an ad hoc committee in 
July 1992, which Nathan chaired. The 
committee returned its recommenda- 
tion for a clinician scholar track in 
December 1993. 

Much debate ensued during consid- 
eration of this proposal about about 
whether the word "clinical" should be 
in the titles of faculty appointed to the 
track. "Two different schools of 
thought emerged and both camps felt 
very ferventiy," says Clyde Evans, 
associate dean for clinical affairs. One 
group felt that one's clinical designa- 
tion should remain in his or her acade- 
mic tide — barkening back to the titles 
of the fore-mentioned clinicians, 
whose spirits guide this track — while 
others felt very strongly that no dis- 
tinction should be made among the 
ranks of full-time professors at the 
school, so as not to reduce the clinical 
track to one for second-class citizens. 

Nathan comments: "Those of us 
who conceived the idea thought that 
we were trying to create even more 
first-class citizens. We think there is a 
great distinction in that title." 

Finally determined, appointees to 
the new track will be named assistant 
and associate professors of clinical 
(discipline), while those who attain the 
top rank will hold the title of profes- 
sor, without the clinical distinction. 

"A professor at HMS should have 
reached such a level of attainment that 
there would be no reason for differen- 



tiation," says Evans. 

To maintain its role as a scholarly 
ladder, those holding positions in this 
track will be required to produce a 
record of their work through publica- 
tion of clinical observations, case 
reports, analytic studies, chapters and 
textbooks. The requirement does 
allow some flexibihty in the means of 
dissemination of clinical expertise, 
however, as audiovisual presentations 
would also be acceptable. 

Appointments to assistant professor 
of clinical (discipline) will be proposed 
for a three-year term; associate profes- 
sor for five-year terms; and professor, 
as the other tracks, will be a perma- 
nent, tenured appointment. Because of 
the high standards of this position, it's 
expected the number of professors 
appointed to this track will be low, say 
Clark and Evans. 

Te7Ti L. Rutter 




Summer 1995 



II 



40^ 



DYING BOSTON BOTS 




tPAT. 



><^\v: 



Given Only Four Months to Live, Alfred Seymdur^R^inli 
Heart Malady and in His Room inThorndykelM^mbrialfc 
on the Progress of Fatal Disease— He %fusedjlel 



B)tM. J. ROItKNAl'. JR. 

AdoIA^ r»ni«tk«ble fhipt*r 
hu bnv iildril In Ihr ilorloua 
tnidJUon of Ihf ThomtlTk^ M^- 
mortAl |jlH>r»UirT of thf Boston 
CHy HotplUl and •nolhrr n«m< 
hA< b^«n addrd lo Ihr Irflon nt 
honor of tbr in«dlc«l profnction. 

U U Ihf Btorj of the lut foar 
monUii In Ibr llfr of Alfm) S'T- 
moor Bflnh»rl. % r>orrh«tcr boy. 
honor trmdaalr of li«r»»lil Col- . 
I^« and brUllant younic medical 
imilil. nbo knoolni Ihal hli 
il *? ir*TT namb*Tfd, drToled 
tb* to ■ rrfat, final rlTort In 
tb« c«o»e of homanllr. 

Belnhart'a ambition wan In add 
I* the «lor« of mrdlral knowl- 
f4|t. Hr had worked hli way by 
Ifholanhlpi throojh ilarrard 
nwdlral achool lo utand on the 
thmhold of aj»fiilnp»a and Ihr 
alUlnnirnt of hl« «oal. Then 
drmlh rrarhrd oat a hand to 
warn him that hia time had 

Four month* to live! Only he 
knew II. Bot death did not Ond 
■ htm unprepared. lie had built 
A atroDC. loandallon for a life- 
time of jRelal aerrlrr. lie had 
•Jngle^ out for hh llfe*« career a 
• tody of the dl'eate whirh wai 
lo fell hot not lo roniiaer him. 
When the lell-lale «lfn appeared, 
he threw to the winda all Ihouthl 





,.,J 



ciT V or po6Td 

OFFICE OF THE • 

•o»rON MASSaCWu 



Mrs. Lona Rolnhnrt, 
174 Harvard Stroot, 
Dorcho8t»r, M«»B«chu««tt*' 

Htxu- Mtb. Rolnhirtt 

I hllVB l*i 

metit In th" rteat.'i of your' Bi)! 

an undergraduato of Harvard ' 

of th« hlghnnt ottalnnenta., 

I'' 

Hny I pl-ajf' 
HSauranco of Tiy sympathy •^-t 

I nave laa 
of lli« Harvard Medical bchool,^ 
by a hnurt malady, and dsspUaj 
hfl nada a noat valued and dlllH 
nrfoctlnr, Ihe henrt, Includtn 
Hnya of Inmnne nuff-rlng, well 
1 "fortitude that has brought 
asooclated wltn the profeailonj 
«o brlUlaAt a student. 



Diary of a 
Fatal Illness 



by Bunon I. Korelitz 




6. 1931 



CE FOR MEDll 



jrilliant Harvard Medical Student, Brav 
1 o/atory at City Hospital Dictated to the 
I of Drugs Because They ^^ Would Clouc" 



ttiber 5, 1931 




your bereave- 
■ Seymour Relnhart 
ty, and a youth 




.at while a student 
< son was stricken 
lonstant suffering 
■tudy In dlaeasss 
•on case, and during 
'ofeailonally »ltB 
Ihe tribute of those 
« In which ho was 



a youth to the 



ir , of your son 
■ofesslonal ldou)s, 
.fo alth « singular 
Indllnees of spirit 
dall7 suffering, 
' -lost hallowed 



IJor. 



You MIGHT WONDER WHY I, A GAS- 
troenterologist, am presenting the 
story of Alfred Reinhart, who hved 
with and died of a cardiac disease at 
age 24. 1 will explain this later. 

In 1942, as a medical student in 
Boston, I had read an article in the 
Journal of the Mount Sinai Hospital by 
Soma Weiss, professor of medicine at 
Harvard Medical School, entitied 
"Self-Observations and Psychological 
Reactions of Medical Student A. S.R. 
to the Onset and Symptoms of 
Subacute Bacterial Endocarditis." I 
had been touched by these observa- 
tions about the short life of this bril- 
Hant medical student, who just a few 
years later might have been saved by 
sulfonamides and penicillin. 
Weiss, who was Alfred S. 



12 



Harvard Medical Alumni Bulletin 



D PAGE_THKKE. 



tALJCIENCl 

Sged Excruciating Pam c 
tliUst His Observations 

W the Symptoms" 



Of hu tn™ T^'rata -Ji* o>«> 

' „o»i «».' b!»<i •<> *""' I'r? * " 

v\ unt'.mfly <J««lt> «« » r'»- ■'™ 

htwoilal and b«:amr fi«niu»r ^'lo 
Swm.; ..( ««« eompllt.uon. .1 
normally !oll<i« 

Stuav'-n« his wn •^«-'' "'. I" ' 
vlnc-d ihal «ti»t (it mign'- rt«.vo 

'r*«.rdKU. 1" •'•^J,'™,?;'?^ 
.sirrpUwciJcUJ term P'""f»:" "* 
lUf blood jyitfm. diMolvmi U» 
blWHl mipliKi'S "h;''' "'"^S; 
t)ecomr> ■<llfl-i.-«d thr«>i«l» the Jt; 

t It WM 'Jils pwulEar symptom wf 
''nrriirred in R'lnhBrt'* ciuw nf 

SliS .ith >-.i» "">""' 'sii^'f' 

law at tluMf home m Dnmi(«t*r 
I Janiian- o( IhU yi-ar. Ulf df all ^1 
I faincr had broken up tila home 
I in hU brotherJ opinion did much 
Iprrripiuie ihe !>t«' dlwjj' 
' Al Ihc dinner uble (K-inhan s 
ideoly pulled baelc his ''«>' °" 
■irn« «ere llie lei! '.ale ipou. a 
»nich aa a man «ell- accUJlomec 
fliji-h signalj. meanl bu( one lbin« 
wraed w hU JUter-ln-law and - 
-Do you see Lheae' I wl" be dea. 
four monlha " 

In imlancei ot the 5ub-acut» 
lacti. the tpou do not la.it lon8 
may not recur. Remhart ir.td to re 
medical men who would undersi 
ihem that nlBhl. laie lo June, but 
irable to In "the momlnil ihe syi 
loma had pracllcallv disappeared 
\f knew It would be dlfTlcult to e 
\ince anyone save cloae ineod.* 
able doctors that his days were ni 
bered. . ,, , 

He went 'o New York cll7 for 
ntit lime In his lUe. to consult 
Llbman o( the Rorketeller Foundal 
world-renowned authority on the hf 
but Dr Ubman was in Europe, not i 
I lo reium «> the young man hur 
t tiaclc lo BoMon ;o ultUze ever7 po^' 
I moment of hf, fleellnj :Ue 
I It had lonit been hLi ambillnn to ' 
Itlnua hb heart siudie with Dr. » 
' WeLW, asswianl prof -sjor of medl 
,-k' Harvard medical school, ^h) 
t\m-.i his wori at «!■• Bnilon ri'v 1 
^iiai. He went iinmeonT -^ 

WeiiS and unfolded e-er- 

,«e. then <e".;cd >!•-'■ i 



Reinhart's preceptor, wrote in his 
introduction that, "much has been 
written on the bacteriological and 
immunologic aspects and on the post 
mortem findings in Subacute Bacterial 
Endocarditis, but the symptoms have 
received surprisingly little considera- 
tion. It is indeed a rare opportunity in 
any disease to obtain an intelligent and 
complete story with subjective sensa- 
tions well related to objective findings. 
Alfred S. Reinhart was a fourth-year 
student in the Harvard Medical School 
and a young man of exceptional ability. 
It is hoped that physicians may read 
with profit this record of his keen self- 
observations with its philosophical 
remarks, written during the course of a 
disease which he recognized as hope- 
less." 



The following quotations come 
from the pubhshed paper and the orig- 
inal unpublished notes of Soma Weiss. 
Reinhart's remarks are interspersed 
with comments of my own obtained 
from a variety of sources. Reinhart 
wrote: 

"Dr. Weiss has generously loaned 
me the services of a Hospital 
Secretary for several minutes every 
day. It is my plan to spend these 
minutes on the evolution of a gen- 
erally fatal disease, and my design is 
to constitute observations on its 
natural history and course includ- 
ing memoirs of the subjective reac- 
tions of a patient to that disease. 
The pathogenesis of a disease must 
be sought usually in the records or 
reactions long antedating the 
immediate symptomatology. In this 
regard, I must look for the genesis 
of the present disease at least ten 
years back to the time I was 
afflicted with chorea and rheumatic 
fever with resulting damage sup- 
posedly only to the aortic valve. 
The fact that the only or principle 
lesion was aortic is, of course, of 
significance in the understanding of 
later events. Aortic regurgitation, as 
is well known, carries with it a syn- 
drome of hemodynamic phenom- 
ena, which are among the most 
striking in the entire field of physi- 
cal diagnosis. 

"For ten years now, I have carried a 
blood pressure ranging on the aver- 
age of i6o systolic and o diastolic, a 
fact, which translated into physical 
emotions means, especially when 
we consider the existence of the cor 
bovinum of aortic insufficiency, 
that every ventricular systole is 
sensed by the patient with no effort 
on his part. The physical discom- 
fort of being forced to experience 
every ventricular systole over a long 
period of years is not to be under- 
estimated, and I had often felt will- 
ing to sacrifice many things in 
order to feel again how it was to be 



/ had been touched by 
these observations of 
this brilliant medical 
student^ who just a 
few years later might 
have been saved by 
sulfonamides and 
penicillin. 



able to live without feeling my 
heart beat. With this physical and 
psychological handicap, I was able 
to complete perhaps with a better 
than the average degree of success, 
school, college, and three-fourths 
of medical school." 

Who was Alfired Reinhart? His par- 
ents emigrated from Eastern Europe 
in the late 1 8oos and settled in Boston 
where all three of their children were 
born, the oldest in 1898 and Alfred, 
the youngest, in 1907. 

Reinhart graduated from grammar 
school at 1 1 , after receiving several 
double promotions. He was bar mitz- 
vahed at 13, but a year later developed 
St. Vitus's Dance and was admitted to 
the Peter Bent Brigham, where he 
could not be held down and was 
treated with ice cold showers. His fam- 
ily doctor warned that he might not 
live overnight. This presumably was 
the onset of his rheumatic fever. 

He lost a year of school because of 
illness, but his mind didn't stop work- 
ing and he read and absorbed informa- 
tion on many topics. He entered 
English High School, where he con- 
tinued to excel. Though he was not 
robust, he remained well for the next 
five years. 

He was admitted to Harvard 
College in 1924 at age 17 and majored 



Summer 1995 



13 



in government and English. His main 
interests were law and writing and one 
of his articles was published in the 
JSlichigan Laiv Review. He was 
appointed an assistant literary editor of 
the Boston Transmpt and supported 
himself during college by writing book 
reviews. As he approached graduation, 



influenced by his own illness and 
impressed with how little was known 
about it, he decided to switch his 
major and apply to medical school. 

He entered Harvard Medical 
School in 1928 and, until the fall of 
1 93 1, was able to actively participate. 
He moonlighted as a subintern, made 




"7 was trying to 
study medicine and 
each known fact lit- 
erally seemed to he 
hammered into my 
head by a cannon. " 



house calls on charity patients, and 
found time to do laboratory research. 
He even wrote a paper on the origins 
of rheumatic fever, which was pub- 
lished in 193 1 by the New England 
Journal of Medicine. During his three 
years of medical school, he acquired 
the medical acumen to understand his 
own case: 

"There began to shape themselves 
in my mind three fears relative to 
my ultimate fate, which albeit, I 
had not usually looked on before as 
being very near. I know there were 
always three octopi ready to grab 
me in their tentacles at the first fea- 
sible opportunity: i) a recurrence 
of Rheumatic Fever, 2) cardiac 
decompensation, for I was leading a 
very active life, and 3) subacute 
bacterial endocarditis." 

Subacute bacterial endocarditis first 
entered his mind in January 193 1, out 
of both his knowledge that it was pos- 
sible and his subjective feeling of full- 
ness in the right upper quadrant, 
particularly when taking a hot bath. 
He also noted early clubbing of his 
fingers. 

"I thought the wisest policy would 
be to consult those who knew more 
about medicine than I did, and I 
was referred to the office of Dr. A 
who found no signs of subacute 
bacterial endocarditis." 



14 



Harvard Medical Alumni Bulletin 



"I subsequently learned from the 
unpublished notes of Soma Weiss 
that Dr. A was Samuel Levine, the 
famous cardiologist. Reinhart did 
well until May 193 1, when while 
running across the street to avoid 
an oncoming automobile, he expe- 
rienced a "procession of extrasys- 
toles unprecedented in their 
frequency. The condition grew 
worse, study and even sleep became 
impossible, and life itself was 
almost intolerable. I was trying to 
study medicine and each known 
fact literally seemed to be ham- 
mered into my head by a cannon. 
The only relief that I could devise 
was getting up at night and walking 
around, thus increasing the heart 
rate. 

"With two of my National Board 
examinations yet to be taken, at 
approximately quarter to twelve, I 
remember distinctly getting up 
from my chair, removing the left 
arm of my suit coat, and there on 
the ventral aspect of my left wrist 
was a sight which I shall never for- 
get until I die — fifteen or twenty 
bright red, slightly raised hemor- 
rhagic spots about one millimeter 
in diameter which did not fade on 
pressure and which stood defiant, 
as if they were challenging the very 
gods of Olympus. There was no 
mistaking the sign; it only had to be 
read. I calmly said to my sister-in- 
law, who was standing nearby: I 
shall be dead within six months." 















Reinhart called Levine, whom he 
knew personally, but Levine was out of 
town at a convention. He then called 
"Dr. B," who, from Weiss's notes, I 
learned was Herrman Blumgart, direc- 
tor of medicine at the Beth Israel 
Hospital, another of Reinhart's pre- 
ceptors; he too was at the convention. 
Eventually Reinhart regained his com- 
posure and tried to sleep. 

In the morning the spots were not 
so red. Their disappearance and the 
lack of reappearance proved to be a lit- 



tle embarrassing in later weeks when 
discussing their significance with fel- 
low students and house officers. "This 
must impress the medical clinician of 
the difficulty of eliciting accurate his- 
tories from even the most intelligent 
of patients," commented Reinhart. 

Reinhart would see red streaks on 
his fingers come and go. 

He then had blood cultures and 



Notes on Reinhart by Soma Weiss, who 
coincidentally died of a cerebral hemor- 
rhage, which he diagnosed himself. 

skin tests. The streptococcal skin tests 
were all highly positive except for the 
streptococcus viridans (the organism 
associated with subacute bacterial 
endocarditis), which was considered 
neutral. Since fully positive tests were 
considered "immunity," the results 
were regarded as favorable, almost 
excluding subacute bacterial endo- 
carditis. But as clinicians later learned, 



Summer 1995 



15 



this was just another instance in which 
the laboratory was not king. 

Reinhart was scheduled to start 
fourth-year surgery at the 
Massachusetts General Hospital and 
he also had an appointment with 
Weiss, whom he was going to assist as 
a tutor. Because of the pressure of his 
circumstances, he postponed both. He 
borrowed $ i oo from his brother-in- 
law and took a trip to New York. 

"Incidentally, during a trip to New 
York which lasted almost two 
weeks, I gained several pounds in 
weight despite the fact that I was 
very active during the entire time, 
and secondly I met a young lady 
with whom I became quite familiar. 
Unfortunately, I learned of the 
death of a school classmate from 
subacute bacterial endocarditis and 
the details of his terminal events. 
Despite this I think I never spent 
any two such enjoyable weeks in all 
my life as I spent in New York, and 
returned to Boston feeling a much 
fuller man from the sights I had 
seen, the places I had visited, the 
people I had met, etc. 

"On Wednesday, with the kindness 
of the Surgical Resident of the 
Massachusetts General Hospital 
and with the courtesy of the staff, I 
began my fourth-year surgery and 
enjoyed it." 

At the end of the second week of 
surgery Reinhart noted soreness in the 
back of his knee, which he attributed 
to standing in the operating room. 
While walking up the hill from 
Cambridge Street to Bowdoin Square, 
he started to limp. He left the hospital 
that day at 7:00 PM (early for him) and 
was barely able to reach his home, 
which was in walking distance from 
the streetcar stop. His family doctor 
made a diagnosis of rheumatic fever, 
but Reinhart observed that his knee 
was not red, swollen or hot. 
Nevertheless, he accepted a heavy dose 
of aspirin and oil of wintergreen packs; 



"/ have freed myself 
from God knows 
whaty merely by 
breathing out the last 
drop of breath that 



was in me. 



•)•) 



they were not helpful. 

After a week, Levine came to see 
him at home; he too made a diagnosis 
of rheumatic fever and advised hospi- 
talization. Reinhart expressed his fear 
of subacute bacterial endocarditis but 
Levine reassured him. 

According to Reinhart, the house 
officer at the Peter Bent Brigham took 
his history, asked for the chief com- 
plaint and Reinhart replied, "subacute 
bacterial endocarditis," to which the 
intern and the resident laughed. 

Treatment was an "anti-rheumatic 
regimen with Salicylates and 
Bicarbonate to the extent of one 
gram of each per hour until I 
should hear Cathedral bells ringing 
in my ears. When there was no 
response, the possibility of infec- 
tious arthritis was also raised. On 
this basis a second blood culture 
was taken and my fate was sealed. 
The green-producing streptococcus 
was found on the culture medium, 
and the diagnosis was now unfortu- 
nately confirmed. 

"Dr. Levine and Dr. D. approached 
my bed with sober faces. Before, I 
could always fimd a leeway out, 
however untenable, but now I was 
confronted with the dictum ultima- 
tum from which there was no 
escape. I calmly accepted the news 
and in return proposed the idea of 
going to Rockefeller Institute as a 
patient for experimental investiga- 



tion. By this plan I had nothing to 
lose, possibly something to gain, 
and in any case, science would be 
the benefactor." 

As fate would have it. Homer Swift 
was away on vacation, as were the 
other leading physicians at Rockefeller 
Institute. Reinhart stayed in Boston. 
He was treated with Pregl's solution, 
an iodine-containing preparation used 
intravenously at daily intervals for 
three or four days. His temperature 
did seem to come down, but then he 
had the first of his splenic infarcts. 

"As I look back on this therapeutic 
procedure it seems only logical that 
it should be a failure, for even 
though the blood stream was steril- 
ized for a day or more, as soon as 
the drug was out of the system the 
original focus would become active 
again, and the disease takes its 
rational course. Dr. D. then tried 
intravenous solution of sodium 
cacodylate. This was followed by 
polyvalent anti-streptococcus 
serum, which, since the skin test for 
sensitivity was highly positive, 
required desensitization — ^which I 
was willing to submit to despite the 
risk of serum sickness and lack of 
success. By this time, I was quite 
reconciled to my fate — I am 
entirely sincere when I say that I 
sought new treatments not in any 
serious endeavor to cure the disease 
or prolong my life but truly to sat- 
isfy that something be done." 

Reinhart wrote about the daily 
attempts at intravenous infusion by the 
house officer; often four or five 
attempts were necessary. "It was a very 
discouraging procedure for me to have 
to submit to this torture every day, but 
I never muttered a word in protest, 
knowing so well how little effective 
protest would be under the stringent 
principles of ethics which pervade our 
profession." 

Perhaps his most dramatic descrip- 
tion concerned his own splenic infarcts 



16 



Harvard Medical Alumni Bulletin 



occurring in the course of subacute 
bacterial endocarditis. He questioned 
whether the older clinicians such as 
Osier and Janeway, who had stated 
that infarcts occurred with indescrib- 
able suddenness, were correct. 

Reinhart wrote: "It is my impres- 
sion its onset was anything but 
vitally acute. At approximately mid- 
night I noticed that it was slightly 
uncomfortable for me to lie on my 
left side without any localization. 
One or two hours later it became 
uncomfortable to be on my back, at 
three o'clock I was generally 
uncomfortable and at four o'clock I 
was sitting up in bed in distress. 
The nurse wanted to call the house 
officer, but I asked her not to. At 
five o'clock the pain in the left 
upper quadrant became intolerable 
and I requested assistance. 

"Every so often in our daily social 
contacts, we are overtaken by some 
remark or deed which we cannot 
fathom or understand. It was just 
such a statement which greeted my 
ears at this time. Whether through 
sheer indiscretion or through some 
personal factor, which I did not 



understand, the night nurse 
informed me that the doctor's reply 
to my request for assistance was: 
'Tell Mr. Reinhart that, if he is 
going to get embolic phenomena, 
to get them at a more earthly hour.' 
(The house officer did later come 
and apologize.) 

"The only other important possi- 
bility for my pain was a renal 
infarct which I feared inestimably 
more than a splenic infarct. I could 
not have many qualms about losing 
a few cubic centimeters of an 
organ, which physiologists have 
never found too much use for, but 
the prospect of renal infarct 
brought up within me visions of 
uremia, convulsions and coma." 

The second splenic infarct was 
much worse "and it was comforting to 
me in my agony that I had such med- 
ical and nursing service at my immedi- 
ate call as I should require. It seemed 
to me that the pain in the spleen is 
intensified not only by lying in any 
direction but by drinking fluids — even 
the slightest distension of the stomach 
causing pressure on the already sensi- 



tive spleen." 

Reinhart then accepted morphine 
and observed that it was just as effec- 
tive taken orally as parentally. He felt 
his reaction to the drug was somewhat 
paradoxical in that he had none of the 
pleasant subjective reactions as one 
supposed, and "I have experienced no 
sensation or other reaction which 
would urge me to seek its fruits again." 

About his extrasystoles, he wrote: 
"It has always affected me as if a 
cannonball, shot point blank at my 
brain, like a terrific explosion 
occurring within the narrow and 
limited confines of a calcified skull 
which refuses to yield to the com- 
pressing force. I had even at times 
attempted the very dangerous 
exploit of exerting double vagal 
pressure against all the advice of 
famous clinicians, but this pressure 
neither killed me nor stopped my 
attack of paroxysmal tachycardia." 

Only a deep inspiration would help, 
but he was also having splenic infarcts, 







^^S/^ 



'""^i 



>s* 



^ 






Summer ioq'c 



17 



No classes were held 
at Halyard Medical 
School on the day of 
his funeral 



the pain of which was markedly accen- 
tuated by the inspiration. He solved it 
by forced expiration, and wrote: "I 
have freed myself from God knows 
what, merely by breathing out the last 
drop of breath that was in me." 

Alfred Reinhart died soon there- 
after, on October 31, 193 1, at the 
Thorndike Memorial Laboratory of 
Boston City Hospital. He had related 
every symptom of his illness until two 
days before his death. No classes were 
held at Harvard Medical School on the 
day of his funeral. 

A letter from Mayor James Curley 
was published along with Reinhart's 
story in the Boston Herald. Editorials 
appeared across the country, including 
the New York Times, with captions and 
statements of many varieties: 

• "Because of his great love for 
Medicine and his desire to be of 
service to mankind, he, himself 
knowing that his death was immi- 
nent, planned the minute details 
concerning his autopsy with the 
professor of pathology at Harvard 
Medical School." {Boston Herald) 

• "His grasp of the immediate 
problem was perfectly amazing, and 
his knowledge of all the literature 
bearing on a point was always at his 
finger tips." (Soma Weiss) 

• "His thoughts were inspirations, his 
mind was romantic with imagina- 
tion." (a Boston newspaper) 
Condolences arrived from friends, 

classmates, teachers and strangers who 
had read about his case. One of the 
most beautiful came from Weiss, who 
wrote: "After his death, I went over his 
notes with particular care and was 



more impressed than ever by his keen 
observations and ability." Levine 
wrote: "I would be proud to have a son 
of his sort and his purpose in life." 

At the 60th reunion of Reinhart's 
Harvard Medical School class in 1992, 
classmate Seebert J. Goldowsky said: 

"In the spring of 1932 Harvard 
Medical School sent out into the world 
120 ambitious starry-eyed fledgling 
doctors. We should not forget the 
bright young classman, who shall 
always remain young, Alfred Seymour 
Reinhart, who tragically passed away 
during our fourth year of a disease he 
would now survive." 

From his death bed at Thorndike 
Memorial, Reinhart wrote this letter 
to his nephew: 

Jasori my Love — 

To you I leave my watch, which 
Grandpa gave me, and my Phi Beta 
Kappa Key, which you will keep as a life- 
long remembrance. 

I leave you also my libraiy in your 
house now. 

I hope you will live long and keep well, 
that you will go through school and college 
and tiy by all means to go to Medical 
School. If you can go to Harvard, my 
record may possibly do you some good, 
although in your time there will probably 
be few to remember me. 

Remember your Parents and your 
Health above all things. Obey, honor, love, 
respect your father and mother and you 
will be honored and respected by all. 

Do not forget by any means to get at 
least one or two good vacations a year. 
This is especially true as you grow older 
and older. 

Be also devoted and loving and respect- 
fid to your parents' other children. 

Be kind to people and be truthfiil and 
hojiest at all times. 

As the first offny nephews I love you as 
I could love few people and I hope you will 
live in a way to merit my hopes for you. 

Uncle Alfred 

Alfred's mother lost her husband 
that same year and came to live with 
her daughter, Ada, in Lawrence, 



Massachusetts. 

That daughter was my mother, Ada 
Reinhart KoreHtz, born in 1900 and 
still alive and well. Jason, who received 
the deathbed legacy, was my older 
brother; he devoted his professional 
life to journalism. I was the second 
son, five years old at the time of my 
uncle's death, his legacy was not 
intended for me, but I received it 
nonetheless and took it deeply to 
heart. 

Throughout my professional life, I 
have kept my uncle's photograph on 
my desk, next to those of my parents, 
wife and daughters. Alfred's legacy has 
been a source of enduring inspiration. 
I will always be grateful beyond words 
to my grandmother, my mother and 
Uncle Alfred for instilling in me early 
a passionate desire to become a physi- 
cian, a profession which has provided 
me with profound fulfillment and end- 
less satisfaction. ^ 

Burton I. KoreHtz is chief of the Section of 
Gastroenterology at Lenox Hill Hospital 
in New York and clinical professor of med- 
icine at the NYU School of Medicine. He 
would like to acknowledge the following 
people who assisted him in researching this 
article: Seebert Goldowsky '52, Edward 
Budnitz '52, Claude Welch '52, Harold 
Levine, Richard Wolfe, Nora Nercessian 
and Herjynan Blumgait (who in /pyj, 
when KoreHtz was a Dana fellow in gas- 
troenterology at the Beth Isi'ael Hospital, 
sat with hi??? for two hours relating his 
7-ecollectioj?s). 



Harvard Medical Alumni Bulletin 



''"HEjj 



Y^ing 




^^mvg:i 



^^^MlJTZ 



Summer 1995 



19 




Harvard Medical Alumni Bulletin 




Transplantation 

Early events in the history of transplantation 
as related in A Miracle & a Privilege 

by Francis D. Moore 




Rejection, the Twins, and Radiation 

(1950-1961) 

Organ transplantation came to our department — or rather, 
patients in our department came to transplantation — on 
March 31, 1951. On that day David Hume transplanted a 
perfectly healthy normal kidney (which had to be removed 
from its host because of nearby cancer) into a 37-year-old 
man suffering from chronic kidney infection with severe 
high blood pressure and advanced renal failure. His demise 
was imminent. The donor kidney was sutured into place in 
the left renal fossa (the normal position of a left kidney). Its 
blood vessels were joined directly to the blood vessels of one 
of the patient's nonfunctioning kidneys, both of which were 
removed. After the transplant he was treated with adreno- 
corticotropic hormone (acth) to stimulate his adrenal 
glands and with heparin to prevent clotting, as well as the 
male hormone testosterone and antibiotics. Even so, the 
operative incision became infected. The kidney never func- 
tioned satisfactorily, and the patient died of renal failure on 
the 37th postoperative day. In present-day parlance, this 
would be referred to as a "random, unmatched, living donor 
kidney, in the orthotopic position without immunosuppres- 
sion, rejected." Immunosuppressive drugs to prevent rejec- 
tion were still unheard of (but in fact were only 8 years 
away). None was used here. 
The David Hume Series 

The significance of this operation lay in the fact that it was 
the first ever to be performed for kidney transplantation 
according to a carefully planned research design, in which a 



Excerpted here from A Miracle & a Privilege: Recounting a 
Half Century of Surgical Advance are portions of Chapters 19, 
20 and of Chapter 31, telling the story of Joseph Murray 
receiving the Nobel Prize in Stockholm in 1990. Reprinted 
with permission of Joseph Henry Press of the National 
Academy of Sciences, Washington, D.C., 1995. 



Summer 1995 



21 



surgical department committed to this study was joined to a 
medical department that included some of the world's 
experts in kidney disease and, again for the first time, with 
the availability of an artificial kidney. All this in a university 
teaching hospital equipped with top-flight consultants and a 
superb pathology department under Gustave J. Dammin, 
who was destined to become the world leader in the pathol- 
ogy and microscopic appearances of organ transplantation. 

This particular operation had another unique feature. It 
was one of the few kidney transplants in which the organ 
was placed in the normal position of the kidney, alongside 
the aorta and the vena cava. Such a position for a trans- 
planted kidney is anatomically difficult and surgically almost 
inaccessible. Only someone with the determination of 
David Hume could and — encouraged by me as his chief — 
wovdd undertake such a procedure. The lesson was learned. 
No more kidneys were put there, even though that was 
where they ordinarily lived and seemed to belong. 

Only 2 3 days later the second patient of this group was 
operated upon. Again, the patient had no significant kidney 
function. The donor, however, had suffered from high 
blood pressure. This time the new kidney was placed on the 
patient's right thigh, its artery joined to a branch of femoral 
artery (the main artery to the leg) and its vein joined to a 
vein of the leg. The ureter (draining conduit for the urine) 
was brought out through the skin. This same technique, 
developed by Dr. Hume, was used in the remaining patients 
of this series. . . . 

George Thorn and I had planned this series of proce- 
dures (dialysis and transplants) together and had asked 
David Hume to carry out the operations because of his 
experience with experimental kidney transplantation in the 
dog and his enthusiasm, surgical ability, and remarkable 
determination. The ethical basis for such a human experi- 
ment lay in only two components: first, the patients selected 
were going to die shortly unless they could get a new kid- 
ney, and second, this experiment was being undertaken 
under the most ideal and favorable circumstances, with con- 
scientious recording of every detail and the availability of 
the artificial kidney as standby. 

Whatever the merit of this series of patients might be, 
whatever criticism we have endured regarding the ethics of 
these early efforts as viewed in terms of present-day mores 
40 years later, whatever the troubles, difficulties, and 
expense we encountered, the fact is that if nothing is ven- 
tured, nothing is won. As it turned out, lots was ventured, 
and, finally, something remarkable was won. Late in this 
series of operations occurred an event the effects of which 
are still to be seen in every country where organ transplan- 
tation is being carried out. 
A South American Doctor 

The big break came in the case of a 26-year-old South 
American doctor who was dying of chronic glomeru- 
lonephritis (generally known as Bright's disease) and its 



lethal complication: extremely high blood pressure 
(2 10/120). The donor kidney came from a woman who had 
died on the operating table during surgery for a narrowed 
aortic valve. The transplant operation was done on 
February 11, 1953. As in the previous case, the kidney was 
placed in the thigh. No ACTH, cortisone, or heparin was 
administered, but some testosterone and antibiotics were 
given. David Hume had suggested that the kidney might be 
enclosed in a small plastic envelope to keep the patient's 
white blood cells away from the outer part of the kidney. It 
seemed to me this was a good idea, though none of us knew 
enough about it to make a sage judgment. So we watched 
and waited. Somehow we were filled with optimism about 
this patient. 

On the 19th day (March 2, 1953), nature smiled on kid- 
ney transplantation — and, as it turned out, on all organ 
transplantation — when the patient began to have a massive 
output of urine, a diuresis that persisted for almost 20 days. 
He required large amounts of intravenous fluids to compen- 
sate for the unregulated loss of fluid through the recovering 
transplanted kidney. After that outpouring of urine, the kid- 
ney resumed normal function that persisted almost 6 
months, and he recovered from uremia (the bloodstream 
disorder seen in kidney failure). His blood pressure 
remained elevated; his own kidneys had not been removed. 
The patient returned home to South America. Five months 
later he returned, his kidney now failing. He knew that he 
was going to die, but like so many patients who have had 
some but not complete success with surgery at the frontier 
of knowledge, he was grateful for the 6 months of life he 
had been given. The magnificent human spirit of such 
patients cannot fail to impress everybody who sees them. 
He had a sort of calm assurance that the experience in his 
case would help others. Litde did he (or we) know how 
right he was and how soon his prediction would be borne 
out. 

He died on the 175th postoperative day, 5 months and 
2 5 days after his operation. He had received a random, 
unmatched, fresh cadaver kidney. Under the microscope 
there was little evidence of rejection — another happenstance 
close match. 

Our experience with this patient as much as any other 
single factor led to the successful initiation of kidney trans- 
plantation a little more than a year after his death, when 
Joseph Murray (David Hume's successor in the lab) trans- 
planted a kidney from one identical twin into his brother. 
Clinical transplantation was born. Because of Hume's work, 
Joe Murray, George Thorn, Gus Dammin, John Merrill, 
and I felt assured that the identical twin experiment would 
be successful and should be undertaken. In addition, we sus- 
pected — as Thorn had so often emphasized — that to control 
blood pressure, both diseased kidneys should be removed. 
In retrospect, it is possible that our failure to follow this 
course was responsible for the ultimate loss of this patient. 



Harvard Medical Alumni Bulletin 



There follows here an account of the development of the artificial 
kidney, of the ^''ann kidney'''' episode, of the early work of 
Medawar, and the nature of human twinning. 

A Twin Dying of Renal Failure 
On October 15, 1954, Daniel Miller, a physician at the 
United States Public Health Hospital in Brighton, 
Massachusetts, called John Merrill at the Brigham to tell 
him that he had a 2 2 -year-old patient (R.H.) who might 
need dialysis on the artificial kidney. Miller was an extraor- 
dinarily perceptive physician. He knew that the patient had 
an identical twin brodier. He understood the significance of 
this fact, noting in the patient's record that the possibility of 
transplant should be entertained. 

At first, John Merrill (physician in charge of the artificial 
kidney) was a little hesitant to take on a patient for dialysis 
who had Bright's disease and for whom dialysis would 
merely prolong the agonies of death. But when Miller told 
Merrill of the identical twin brother and the implied possi- 
bility of transplantation, Merrill assented. The ambulance 
carried the patient from nearby Brighton to Brigham Circle 
on Huntington Avenue. 

When the patient was first admitted he was very sick. 
Because he suffered from chronic Bright's disease, he had 
severe hypertension, a common cause of death in such 
patients. He was incoherent, thrashing about and having 
frequent convulsions. The first thing the physicians did was 
to stop his drugs. Half the medication he was taking was 



discontinued. Soon, he got much better. It was then possi- 
ble to test him and his brother to see whether or not they 
were truly identical twins. Such matching could be done in 
a variety of ways, including configuration of the external 
ear, fingerprints, thumbprints, toeprints, and several other 
tests to detect close physical similarity. Crossed skin-graft- 
ing was carried out by Joseph Murray, who at that time was 
concentrating on plastic and reconstructive surgery. Joe had 
recently completed his surgical residency and had a strong 
interest in research and a commitment to the study of kid- 
ney transplantation in the laboratory. The skin graft showed 
that the twin brothers could accept each other's skin with 
ease and with no signs of rejection. They were truly identi- 
cal. The push to transplant gained momentum. 

Joseph Murray and the First Successful Transplant 
(December 1954) 

After patient R.H. improved a bit on simple management, 
he was sent home for a while. When he failed to improve 
any further, he was readmitted and dialyzed on the artificial 
kidney. On December 23, 1954, the head surgeon of our 
urology division, J. Hartwell Harrison, removed one kidney 
from the donor twin, and Joe Murray transplanted it into 
the patient. The only role I assigned to myself was to carry 
this sacred kidney from one operating room to another, 
from Harrison to Murray, so it could be placed in its new 
host. Leroy Vandam, whom I had appointed Head of our 
Department of Anaesthesia only a few months before, 
administered the anesthesia — a touchy, difficult, and critical 




Murray's 
Medal 

"Now we're going to turn back 
into pumpkins," said Josepli 
Murray's wife, Bobby, as they 
boarded the plane for Boston 
from Stockholm on December 
14, 1990. Accompanied by 
their six children, five sons- 
and daughters-in-law and four 
grandchildren, the Murrays 
had just attended a royal ball: 
the Nobel ceremony, at which 
Joe Murray '43B received the 
Prize for Medicine or 
Physiology. For 10 days they 
were feted in regal style, 
including dinner with the royal 
pair themselves. 

"I was grateful that when the 



king toasted me as his dinner 
partner... I had had much prac- 
tice with learning the proper 
protocol for the Swedish toast, 
'Skol'," says Bobby Murray. 

in 1990 Joseph Murray was the 
co-recipient of the Nobel Prize 
for Medicine or Physiology for 
his groundbreaking work in the 
field of transplantation. He and 
Bobby Murray joined Nobel lau- 
reates E. Donnall Thomas '46, 
with whom Murray shared the 
prize, author Octavio Paz, who 
won the Nobel Prize in litera- 
ture and is Mexico's first Nobel 
laureate, and the other laure- 
ates in this stunning annual 
celebration, where the world's 
greatest contributors to litera- 
ture, physics, chemistry, medi- 
cine or physiology, and 
economics are the guests of 



Summer 1995 



23 



part of the operation, especially in such a sick patient. 

The operation went well. The kidney was placed in the 
lower abdomen, with the ureter running directly into the 
bladder, according to the procedure Murray had perfected 
by experiments on dogs. The blood-vessel suturing was 
done much as Carrel had taught 50 years before. The sim- 
plest of procedures was used for the recipient patient, since 
we were trying to avoid complicated or careless experimen- 
tation with dangerous drugs or medicines. 

When both patients were taken from their respective 
operating tables, they were doing quite well. The trans- 
planted kidney was making nice, clean, clear, yellow urine. 
Although you may never have developed any affection for 
urine, if you or your patients are unable to make any, you 
come to appreciate it. 

A couple of days later the patient appeared to take a sud- 
den turn for the worse, a bit of a nosedive. It proved to be 
only a temporary setback. His kidney picked up again, and 
about a month later he was discharged from the hospital, his 
twin brother pushing him along in a wheelchair toward the 
ambulance to take him home. This was only 18 months 
after the remarkably encouraging experience of David 
Hume with that South American doctor who hoped his 
treatment might help others even though, in the end, it 
failed him. 

In this age of communication it does not take long for 
such discoveries to get around. Word of the discovery of 
ether 108 years earlier spread around the world in a few 
months. News of this first successful transplant took only a 



few days to be known wherever people were studying renal 
failure. Joseph Murray was soon recognized, along with his 
predecessor and collaborator David Hume, as a leading pio- 
neer in surgical transplantation. 

This first successful kidney transplant of 1954, although 
in the fi^eak circumstance of identical twinning, demon- 
strated two basic truths: first, it showed that if transplanta- 
tion of a kidney could be successful over time, the kidney 
would continue to work well, the elevated blood pressure 
would return to normal (usually requiring removal of the 
old, diseased kidneys), and the chemical imbalance would be 
corrected. The kidney could reside comfortably in the 
abdomen in that odd spot down in the pelvis, not too far 
from the usual site of the appendix. Second, and possibly 
more important, it showed that if the immune barrier could 
be overcome (as it was here by a fluke of nature), tissue 
transplantation would be here to stay. 

We feared that the identical twin's kidney, put in the sick 
patient's body, would acquire the same disease that the 
patient formerly had: Bright's disease. After all, identical 
twins have the same sort of susceptibility to just about 
everything. That is exactly what did occur, and it was the 
ultimate cause of failure and death in that first identical twin 
transplant. Eight years later, in 1962, the patient, made well 
by the transplant fi-om his twin brother, developed the same 
kidney disease in the transplanted kidney that he had suf- 
fered in his own kidney. The donor twin, fortunately, 
remained well and unaffected. 

Even those 8 short years of life given to this young man 



honor of King Carl Gustav, 
Queen Sylvia and the entire 
country of Sweden. 

"It is the big event of the year 
in Sweden," wrote Bobby 
Murray, who has been invited 
to speak around the country 
about her and her husband's 
experiences in Stockholm. 
"When we drove in our limos in 
a motorcade to the Concert 
Hall, people lined the streets 
waving little flags and adding 
to the excitement." 

At first, the Nobel committee 
felt his work was too clinical in 
nature for the award. Then 
finally, three decades later 
Murray was awakened at 4:40 
AM by a phone call of the sort 
every scientist hopes for; this 
one came from his daughter 



Ginny: "Daddy, Daddy, I've 
some wonderful news. You've 
won the Nobel Prize." 

Murray admits that winning the 
Nobel Prize has definitely 
changed his life. "You can 
never go into a meeting without 
being noticed," he says. "And 
you can never miss a meeting 
without being noticed." He 
compares being a Nobel Prize- 
winner to being a goodwill 
ambassador for the oi^aniza- 
tion. 

"Joe, you're really joining a fra- 
ternity," Stig Ramel, the Nobel 
director, said to him. "We'll 
call on you." The year after 
their own fairytale time in 
Stockholm, Joe and Bobby 
Murray were guests of the 90th 
Nobel celebration, and Joe 



Murray has served as a repre- 
sentative of the oi^anization at 
meetings and events around 
the United States and abroad. 

But beyond walking on the rich 
blue carpets embossed with 
the Nobel insignia, gazing at 
the queen's diamond tiara and 
walking amongst the tremen- 
dous bouquets of Italian zin- 
nias and carnations that lined 
the reception hall, there is 
another side to winning the 
Nobel Prize: the opportunity to 
travel extensively with the mes- 
sage about the crucial need for 
oii;an donation. In the United 
States alone, 30,000 patients 
are waiting for an organ trans- 
plant. "The fact is, three-quar- 
ters of them will die without 
having a chance of a trans- 
plant," says Murray. "Society 



is not sufficiently aware. 
Everyplace I go, I talk." 

What Murray and the team at 
the Peter Bent Brigham 
Hospital began that day has 
grown into an international 
phenomenon: over 300,000 
kidney transplants have been 
performed worldwide, and 
approximately 50,000 each of 
heart and liver transplants. 

During a recent meeting of sur- 
geons from around the world, 
Murray learned that trans- 
plants were being done in 
India, Africa and the Middle 
East. Indeed, one of his most 
poignant memories from the 
whirlwind travel schedule that 
immediately followed the 
announcement of the prize was 
being greeted at the Singapore 



24 



Harvard Medical Alumni Bulletin 



had tremendous meaning for him. He had fallen in love 
with one of his nurses at the hospital. They were marrried 
and had a family. Like the South American doctor, neither 
of the brothers expressed anything but gratitude for the 
care, caring, and help they had received, even when it 
became clear that the outcome was headed for tragedy in 
the end. 

If transplantation was to help the thousands of patients 
dying of kidney failure every year, it was necessary to move 
beyond the identical twin setting. This was a hard time, 
with black years of failure ahead. 

There follows a brief account of the '^seven black years" and of the 
first successful transplant in an irradiated host, a fraternal twin, 
the procedures carried out by Joseph Murray, J. Hartwell 
Harrison and James Dealy, in collaboration. 

The Advent of Drug Immunosuppression 

(1958-1962) 

Just at the height of our struggles, with whole-body irradi- 
ation and its seemingly hopeless outlook, there appeared a 
flickering candle visible on what seemed to be the most dis- 
tant scientific horizon. It is a matter of some nostalgia to all 
of us who saw this candle that even though it flickered 
faintly, we realized it could be the light at the end of our 
particular tunnel. It might indicate a way to suppress immu- 
nity without the uncontrollable hazards of total-body x-irra- 
diation. Maybe the black years would give way to something 
brighter. 

airport by a group of about 75 
people holding a sign tliat 
read: "Singapore Transplant 
Patients Welcome Dr. Murray." 

It's the patients whom Murray 
says he thought of while stand- 
ing on stage before an audi- 
ence of 1,200 people to 
receive his Nobel medal from 
the king. He thought about the 
patients who lived but also, 
and perhaps especially, about 
the ones who died. Murray says 
he still receives letters from 
the families of those patients 
and they are always filled with 
congratulations and words of 
gratitude. 

"I'm very impressed with the 
altruism that exists in society," 
he says. "Your patients are like 
members of your family." 



That flicker came from a point very close to us in 
Boston: Tufts Medical School. It took the form of an article 
about a new anticancer drug developed by the Burroughs 
Wellcome Company. The laboratories of this British- 
American company had a brilliant young chemist in their 
midst, George Hitchings. He and his assistant, Gertrude 
Elion, had sjmthesized a new drug originally intended for 
anticancer chemotherapy called 6 mercaptopurine (6-mp). 
For the synthesis of this and other key drugs based on the 
body's own chemistry, these two scientists were awarded the 
Nobel Prize in 1988. 

Obtaining this new drug fi-om Hitchings, two hematolo- 
gists at Tufts Medical School, Robert Schwartz and William 
Dameshek, had observed its effect on the immune system of 
experimental animals. They had injected human serum 
albumin into laboratory rodents. Today we would call this a 
xenograft model, in which protein is traded between two 
different species. The animals usually rejected this very 
strange material rapidly and removed it from their blood. 
Because the protein was tagged with a radioactive tracer, the 
rate of removal could be measured. The tag and the foreign 
protein rapidly disappeared from the bloodstream of the 
untreated animal. Schwartz and Dameshek then gave the 
animals 6-mp to observe its effect on the rejection of this 
foreign (human) protein. The drug completely inhibited 
rejection, and the foreign protein persisted in the blood- 
stream. In 1958, these two clinical scientists published an 
article describing the immune suppressive potency of 6-mp. 
To all of us in the transplant field, this result was both 
important and exciting. Researchers are daydreamers at 
heart. It was not too difficult to imagine that this or some 
similar drug might be used to prevent the rejection of 
grafted kidneys. 

There follows an account of the pioneering work of Roy Calne in 
developing 6-mercaptopurine and azathiopjine as immunosup- 
pressive drugs for use in kidney transplantation, work earned out 
both in London and at the Harvard Medical School Surgical 
Laboratories under the direction of Moore and Murray. 

The First Successful Transplantation from an 
Unrelated Donor (April 1962) 
The patient's initials were M.D. Those initials were 
prophetic because he taught so many lessons to so many 
doctors. He was 24 years old when he was admitted to the 
Brigham on January 21, 1962, and referred to Dr. Merrill's 
kidney study and dialysis unit, because he too was suffering 
from chronic Bright's disease. In M.D.'s case, the disease 
had gradually worsened over many years. 

After admission, M.D. was treated by peritoneal dialysis, 
in which a plastic button is placed in the abdominal wall so a 
small tube can be inserted and replaced without pain or 
inconvenience for "blood washing" on the surface of the 
abdominal membrane. The patient was admitted to the hos- 



Terri L Rutter 



Summer 1995 



25 



pital six times during his first month to learn how to per- 
form this type of dialysis himself so he could use it at home 
instead of coming to the hospital for sessions on the artifi- 
cial kidney. Eventually, peritoneal dialysis became less and 
less effective. So the patient became a candidate for kidney 
transplantation. He had no twin, and no close relatives were 
available to act as donors. He began the long wait, knowing 
that he would be one of the first to be treated by drug 
immunosuppression for transplantation and that previous 
patients had not survived. 

For a week Murray and two of his colleagues took turns 
sleeping in the hospital to keep a 24-hour watch in case 
some severely injured or very sick patient died suddenly, 
making a kidney available for transplant. The others on the 
kidney watch were Nathan Couch, who later helped us to 
preserve kidneys better, and Richard Wilson, who would 
within a few years take over from Joe Murray as head of the 
transplant unit. 

There were three false alarms before they finally had 
their donor. On April 5, 1962, an operation was scheduled 
on a 30-year-old man for severe heart disease. For this par- 
ticular operation at that time the patient's whole body was 
cooled. The operation was long and difficult, and when the 
patient was rewarmed his heart would not resume its normal 
beat. He died on the operating table despite a prolonged 
effort to restart his heart. After he died, his whole body was 
again cooled so that he could be put back on the pump-oxy- 
genator (the heart-lung machine) to maintain his circulation 
artificially. His kidneys still functioned well; they were cool. 
And fresh. It took only a few minutes to complete the nec- 
essary arrangements with a helpful and understanding fam- 
ily. One kidney was removed only 40 minutes after the 
patient's death and was cooled further to 4°C. The total 
length of time from the death of the donor to the establish- 
ment of new, warm circulation in the kidney after transplan- 
tation was only 2 hours. 

We knew from our laboratory work that all these cir- 
cumstances were clearly favorable to the transplanted kid- 
ney. In fact, over the course of a few years it was widely 
recognized that this was the ideal way to preserve organs for 
transplantation. At the present time, whenever possible, 
even though a patient may have died of severe head injury 
or a brain tumor, the ideal setting for donation is total-body 
cooling and artificial maintenance of the circulation using 
the pump-oxygenator. This was the first such donation. 

The recipient, M.D., was placed on azathioprine. 
Although the kidney started to put out normal urine at the 
time of the operation, function soon ceased for a full 10 
days. It was a puzzle as to whether this was temporarily 
renal failure of the reversible type or prompt immune rejec- 
tion of the new kidney despite use of the new drug intended 
to prevent just that. 

On the 1 2th day M.D. started to make urine again, and 
on the 1 8th day he made 6 quarts (about i 1/2 gallons) in 



one day! This was reminiscent of some of Hume's early 
thigh kidney transplants. The transplanted kidney can get 
wildly out of control and make much too much urine for a 
while, requiring extensive fluid treatment to keep the 
patient from becoming dehydrated by his own kidney. Such 
a kidney will literally piddle the patient to death if you are 
too slow in replacing the lost fluids. 

On the 39th day, despite recovery of more nearly normal 
function and despite the drug, M.D.'s immune system tried 
to reject his kidney. He had a typical immunologic rejection 
crisis characterized by high fever, severe illness, and 
decreased urine output. This was treated with actinomycin 
D in addition to azathioprine. 

When this crisis subsided, the patient began to improve 
but his blood pressure was still elevated. On the 50th day 
and again on the 62nd postoperative day, J. Hartwell 
Harrison performed an operation to remove the patient's 
own degenerated kidneys. Although the patient was a sick 
man for two such big operations, they were essential to his 
survival. Blood pressure now returned to normal. George 
Thorn's original idea of removing the kidneys to treat 
hypertension was again corroborated by events, this time in 
an extraordinarily important patient: the world's first trans- 
plant recipient on drug immunosuppression. 

There follows an account of the later course of patient M.D. 

M.D. had a hectic and troublesome time. Both he and 
his family, true to the stamp of these patients, remained 
grateful for the extension of his life. But it was not to last for 
very long, because on July 2, 1964, he died of generalized 
infection and severe liver damage. The latter may have been 
due to hepatitis virus from one or more of his transfusions. 
Also, azathioprine can be toxic to the liver. All three of 
these early transplant patients taught doctors important 
lessons that provided a model for the rest of the world. But 
only one, the fraternal twin, survived for a long time, 
remaining well and continuing his work for 25 years. 

On the basis of our care of M.D. , our experience grew 
rapidly. Of the first 1 3 patients operated on under immuno- 
suppressive drugs at the Brigham between April 1962 and 
April 1963, 10 received kidneys from recently deceased per- 
sons, while three were given Matson kidneys. Matson kid- 
neys are fresh when transplanted and require no 
preservation. Those three patients appeared to fare better 
than the others. 

By 1963 kidney transplantation was spreading rapidly 
over the world. We were no longer unique. Most notably 
the technique was picked up again by David Hume, for- 
merly of our department, who had become professor and 
head of the department at the Virginia Commonwealth 
University in Richmond; by Thomas Starzl in Denver, 
Colorado; and by Rene Kliss and Jean Hamburger in Paris, 
where important work in transplantation had been going on 



26 



Harvard Medical Alumni Bulletin 



for some years using both radiation and drug immunosup- 
pression. Roy Calne had returned to London from our lab- 
oratory and then went to Cambridge, England, where he 
became Professor of Surgery and Head of the Department 
of Surgery. He was knighted by the Queen in 1986 for 
introducing transplantation to Great Britain. 

For this pioneering work, Joseph Murray was awarded 
the Nobel Prize in 1990. 

The following excerpt is from Chapter ^i on events in ip^o. 

Attending the Ceremony 

The Swedish, like the British, enjoy laying it on with public 
ceremonies of pomp and circumstance. The Nobel cere- 
mony is one of their greatest annual events, and the entire 
celebration lasts about 10 days. 

At this time of year (December), the sun as viewed from 
Stockholm does not get more than a couple of inches above 
the horizon. The nights are long, cold, damp, and intrinsi- 
cally gloomy, while the days are very short. What better 
time to have this huge, colorful, exciting international cele- 
bration with several events attended by leading figures from 
all over the world? It is a time for fancy clothes, evening 
gowns, and medals pinned to wide red stripes from shoulder 
to bellyband for the European gentlemen. But in point of 
fact, none of that is why the ceremony is held in December. 
It happens to be the time of Alfred Nobel's death, and was 
designated as the time for the event. 

Our trip to Sweden was largely uneventful save for the 
fact that I forgot my pants. I discovered this crippling omis- 
sion on Sunday, the day before the big ceremony. In 
Sweden, stores are open on Sunday. When I got to the 
men's dress-clothes department, a cheerful young lady said, 
in perfect English, but with a charming Swedish smile, 
"Well, well. Another American who forgot his trousers!" 
This is what most people would call tact. 

Suitably attired, we attended the festivities. Joe's scien- 
tific presentation of his work was well done, modest, giving 
credit to his colleagues and predecessors. George Thorn 
and many members of the Murray family were present to 
enjoy the ceremony. 

Kathie looked marvelous in her floor-sweeping gown 
and long, white gloves, an item I thought had disappeared 
from our society when I ceased to attend Boston debutante 
cotillions. We danced at the formal ball after the banquet. 
One of the Murrays' daughters-in-law is a singer (as is Joe's 
wife, Bobby) and had performed in Sweden before. So as a 
specialty of the ball, she sang some jazzy American pieces in 
Swedish and charmed the large gathering. 

The banquet itself is held in the huge town hall, said to 
be the largest single-room banquet hall in the world. The 
1,800 guests were precisely arranged by field of study and 
therefore possibly prior acquaintance. We were seated 
among friends and not too far from the young and sparkling 



queen, diamond tiara and all, and the rather stiff and formal 
young king. 

This Nobel ceremony seemed a long way from the 
smelly dog lab in which the first experimental transplants 
had been done, the workaday world of developing organ 
transplantation, the gloom of death and failure, and our 
excitement in the successes of our long-surviving animals 
and, later, patients. ^ 

Francis D. Moore '55) is HMS Moseley Professor of Surgery 
Emeritus and surgeon-in-chief e?neritus, Peter Bent Brigham 
Hospital. 





X 



J 



Summer 1995 



27 



The Deliverer 



by James Locke Neller 



Whenever I reminisce about my 
learning experiences as a Harvard 
medical student, such recollections 
invariably bring to mind the opening 
lines of a James Whitcomb Riley 
poem: 

When memories keep me company 
and move to smiles or tears, 

A weather-beaten object looms 
through the mist of years — 

The 'weather-beaten object' I envi- 
sion in this case is a very small, very 
dilapidated house on E Street in the 
unwashed environs of Boston, where 
as part of my training, I was intro- 
duced first-hand to the wonders and 
mysteries of obstetrics. This exposure 
to the realities of procreation was 
required (at least when I was there in 
the late 1930s) of all fourth -year stu- 
dents, and consisted of a two-week 
stint delivering babies in the homes of 
lower-income families who otherwise 
could not have afforded any profes- 
sional care at all. Theoretically, this 
wasn't a problem because the women 
had been seen and followed in the free 
obstetrics chnic of the serving hospital, 
and were deemed prime candidates for 
normal delivery. 

In order to make this system avail- 
able throughout Boston's sprawling 
expanse, the medical school had 
acquired a number of small houses so 
that the students on call, usually two to 
a house, could live in the district to 
which they were assigned. Each house 
also accommodated either an intern or 
resident from the obstetrics depart- 
ment of whatever teaching hospital 
was nearest. It was considered a stroke 
of luck if it was a resident, because he 
was usually content to supervise, 
whereas the intern always wanted to 
appropriate the deliveries for himself 



On the first call, we were shown 
through the whole routine and allowed 
to participate only marginally. The 
next time we did it all ourselves under 
supervision. From then on we were on 
our own, with help quickly available by 
phone if needed. It was a matter of 
pride to be able to get by without call- 
ing- 
Each student was required to 
deliver a total of six babies. If he 
couldn't do it in one stint, he had to go 
back another time to complete his 
quota. We all hoped we could get our 
six deliveries in one two-week assign- 
ment, even though it would be a sleep- 
less, nerve-wracking experience, which 
could test the mettle of the strongest. 
Those who were successful were tac- 
itly accorded superior status among 
their peers — a goal avidly sought by 
all. 

It was indeed a pulse-pounding 
experience. Most of us had never even 
seen a baby born. All our training was 
academic, and as good as that was, it 
lacked the essential ingredient of expe- 
rience. To a man, we were filled with a 
heady mixture of anticipation and 
apprehension, anticipation usually the 
strongest. We were scared all right, 
but we loved it: after all, this was the 
challenge we had chosen for ourselves 
and at last we were doing it. It was no 
place for the faint-hearted, but then 
neither was the entire practice of med- 
icine. 

The district houses were little more 
than shacks with the barest of ameni- 
ties. The most important piece of 
equipment was the telephone. It was 
our lifeline. 

I was assigned to the E Street dis- 
trict house. I had hoped it might be 
the one on Chambers Street because 



of a certain fame associated with that 
location. For one thing, it was the 
house where Professor Fritz Irving had 
served his stint when he was a student, 
and that alone made it special. The 
real cause of its notoreity, however, 
was the poem he wrote while on duty 
there — a bawdy parody of his experi- 
ences entitled "The Ballad of 
Chambers Street," written in the form 
of Gray's "Elegy Written in a Country 
Churchyard." The poem was immedi- 
ately recognized as a classic, and over 
the ensuing years became a tradition, 
covertly possessed and memorized by 
all succeeding Harvard medical stu- 
dents. 

Once Irving reached academic 
prominence as the William Lambert 
Richardson Professor of Obstetrics, he 
tried his best to eradicate the thing 
from the face of the earth for reasons 
that are obvious when it is read, but 
the more he tried, the more 
entrenched it became. I reluctantly 
refrain from reprinting it here in def- 
erence to his memory. 

Disappointed though I was by the 
locus of my assignment, I reasoned 
that at least I'd be undergoing the 
same experiences that he had had, and 
in the same general area. With this to 
inspire me, I was determined to rise to 
the heights and prove myself worthy of 
such a celebrated mentor. 

There was no one in the E Street 
house when I arrived. I checked the 
address to be sure I was at the right 
place. I hadn't expected much, and I 
was right. It was a tiny, wooden 
cracker box of a place, with peefing 
paint and two cracked and patched 
windows, one on either side of the 
flimsy front door. Four railed-in steps 
led up to it, without a vestige of a 



28 



Harvard Medical Alumni Bulletin 



porch. The small yard was brown with 
dead grass and was littered with refuse. 

I shrugged, made my way up the 
less than solid steps and knocked. The 
door fell open at my touch. I stuck my 
head in and, when no one answered 
my query, entered. The interior was a 
perfect match to the outer facade. The 
floor was bare. There were two cots, 
two desks with chairs, a card table with 
two similar chairs, a fake fireplace with 
a mantle upon which rested a three- 
dialed radio shaped like a Seth 
Thomas mantle clock, and a telephone 
with a cord long enough to reach any- 
where in the room. On one stained 
wall was a large dartboard with six 
darts in the bull's eye. On the other 
was a large framed print of a Maxfield 
Parrish idyll that seemed strangely out 
of place until I noted the many dart 
holes in the reclining nude figure. 

I dumped my small bag of necessi- 
ties on one of the cots and dialed my 
lifeline number on the wall-phone to 
report in. I was told that Dr. Van 
Etten, the resident on duty, was help- 
ing student Claj^on with a delivery 
and would soon be back. There were 
no delivery calls for me at present. I 
heaved a sigh of relief and looked 
around. 

In the cul de sac that passed for a 
kitchen was a sink full of dirty dishes. 
On either side of it were a late 
Neocene refrigerator and gas stove. In 
the refrigerator were milk and eggs, 
and a number of candy bars. There 
were a few cans of hash, baked beans 
and vegetables on the cupboard 
shelves above. The inevitable can of 
ground coffee, now nearly empty, and 
some jars of salt and sugar made up the 
rest of it. 

Off the kitchen was a door leading 
to a small bathroom with a tub- 
shower. At its far end, another door 
led into a small but startlingly clean 
and tastefully decorated bedroom — 
obviously the resident's quarters. 
There was even a curtain on the single 
small window. The bureau held a 
chrome framed picture of a very pretty 
young woman holding a plump infant 



in her arms. Quite obviously, Van 
Etten was married and his wife had 
had a hand in the decor of his tempo- 
rary duty station. I felt as though my 
presence was somehow defiling the 
place, so I went back in the living 
room and slumped in the springless 
lounge chair. The place smelled of 
tobacco and bug killer. I decided that 
it was not exactly the Taj Mahal, but 
what the hell, for two weeks it was 
home. 

When Van Etten arrived, he turned 
out to be a very nice guy with a sharp 
mind. We shared a cup of coffee and 
he told me I was lucky, because the 
other student who was to have been 
my partner was ill and couldn't come. 
Although I regretted the plight of the 
absent partner, I couldn't help being 
elated by the news: it was a golden 
opportunity for me to make my quota! 
Van Etten assured me he'd take any 
deliveries I couldn't handle, and would 
meticulously herd me through the first 
one so that I'd learn the routine. 

We'd no sooner turned in than the 
telephone rang. My heart began to 
thump in anticipation of my first expo- 
sure to the world of obstetrics. I 
grabbed the phone. Trying to sound 
calm and knowledgeable under the cir- 
cumstances took a lot of discipline, but 
somehow I managed it. Carefully I 
accumulated the necessary data, not 
only as to location, but also the symp- 
toms manifested, and other things nec- 
essary to assess the urgency of the call. 

When I was through, I turned to 
get Van Etten and was surprised to 
find him standing behind me. It was 
evident that he had carefully evaluated 
everything I'd said and I was happy 
indeed when he congratulated me on 
how I'd handled things so far. After a 
short discussion of the situation, he 
agreed with my conviction that it 
appeared to be a true emergency call 
requiring immediate response. 

I hardly remember the hurried ride 
through the dark and winding streets 
to our destination, but do remember 
the climb up several flights of dimly lit 
and littered stairs to a single-room flat 



about the size of an ordinary kitchen. 
The mother was 30 years old. She had 
two children and was married to an 
intermittently employed chimney 
sweep whose restricted income from 
the looks of things barely covered his 
beer bill, much less the food and rent. 
She was placid and cooperative and 
bore her labor pains as she apparently 
bore everything else in her life — with a 
Mona Lisa smile of acceptance and a 
quiet stoicism. Her labor pains, now 
timed at intervals of five minutes, were 
evidenced only by a slight squinting of 
her large and luminous dark eyes, and 
a barely audible forced and prolonged 
exhalation. 

As things settled somewhat, I was 
appalled by the evident poverty and 
lack of privacy around me. In addition 
to the two of us, the small room also 
held her two children, her T-shirted 
and stubble-bearded husband who 
seemed concerned but completely 
uncommunicative, and an unidentified 
woman, probably a neighbor, who 
critically watched everything that was 
taking place before her. 

I was saved from extensive socio- 
logical ruminations by the necessity of 
observing in detail Van Etten's routine 
in preparing his equipment and the 
patient, as well as his masterly method 
of establishing the necessary authority 
and control that were essential in 
order to accomplish the delivery with a 
minimum of problems. 

The actual birth, when it came, was 
almost anticlimactic. Van Etten had 
little to do other than speak soothing 
instructions to the mother, receive her 
delivered child, tie and cut the cord, 
and put pressure on the uterus as he 
awaited delivery of the afterbirth. In 
the process, he allowed me to hold the 
infant upside down and by firmly pat- 
ting its chest, stimulate its first volun- 
tary respirations. Mindful of the 
remembered textbook fact that new- 
borns tend to be slippery and hard to 
hold, I carefully performed the requi- 
site act and was rewarded almost at 
once by a gasping cough followed by a 
loud cry of infantile outrage for having 



Summer 1995 



29 



been cavalierly ushered into the world. 
I then placed him on a clean sheet, 
and under close supervision was 
allowed to tie and cut the cord. This 
done I washed the infant with warm 
water, wTapped him in a blanket and 
gave him to his mother. She received 
him with a look of glowing maternal 
joy, cradled him in the crook of her 
arm, and with soft sounds quieted his 
protestations. 




The ambience of the scene sud- 
denly took possession of me: how like 
a Raphael painting of the Madonna 
and Child. For a fleeting moment I 
could almost feel the intensity of the 
mother's emotion, but being male, 
quickly pushed the sensation aside as 
something not in my purview. That 
memory, though, has remained unsul- 
lied and instantly recallable ever since. 

While all this was going on, 
between gulps of beer, the father occa- 
sionally glanced at the proceedings 
with an expression of mild amusement. 
The neighbor woman knitted in a 
tempo that closely paralleled the 
action, her eyes unblinking and all- 
seeing. She occasionally nodded with 
satisfaction if the goings-on pleased 
her. The two children, although their 
attention span was fortunately short, 
were fascinated and at times transfixed 
by what they saw. It must have been 
quite a remarkable experience for 
them. 

As for myself, I was exhilarated. I 
felt saturated with many new sensa- 
tions and learning experiences and too 
intensely preoccupied to define any 
subjective reactions clearly. That 
would have to await full reassessment 
at a later, less emotional time. 

When it was all over, we packed up, 



30 



gave oral instructions (no one could 
read) and returned to "our world," 
happy in the belief that we had done a 
commendable job and ushered another 
child safely into being. 

The next call came two days later 
and this time I was in the driver's seat. 
Somehow I managed to handle it with 
out any outstanding errors, and the 
patient cooperated by having quite an 
easy delivery. Van Etten nodded his 
approval when it was over, and for a 
fleeting moment I felt like a real doctor, 

Actually, I was little more than a 
midwife and in my heart I knew it 
well, but that knowledge could not 
lessen my sense of accomplishment. It 
was another milestone on the long 
path to becoming a professional. 

Back at the district house, we 
hashed over everything we could 
remember to see if my approach and 
actions could be improved for the next 
experience. I fell into bed and in my 
dreams did it all again, this time to 
perfection. 





The next experience was not at all 
what I expected. In a fit of anticipation 
over going to my first autonomous 
delivery, I practically fell all over 
myself to get there. By the time I 
arrived like a knight errant to save a 
life and be a hero, it was all over. The 
baby had been precipitated into the 
toilet, placenta and all! The mother 
was drunk, and didn't even know she 
had given birth. I fished the baby girl 
out of her watery porcelain crib, suc- 
tioned her out and whacked her on the 
back. After a few worrisome moments, 
miraculously, she suddenly began to 
sputter and cry. 

By the time I had taken care of the 
cord, secured the child, called for help. 

Harvard Medical Alumni Bulletin 



dealt with the placenta and the inebri- 
ated mother, and gotten things under 
the aegis of Social Services, it was 
almost dawn. Somehow I managed to 
get back to E Street, where I fell into 
bed and oblivion. Fortunately there 
were no more immediate emergency 
calls to interrupt my much needed 
rehabilitation. 

When I finally awoke and had a 
chance to organize my thoughts, the 
lugubrious humor of the preceeding 
events struck me. When I got over 
that, I decided that things weren't so 
bad. After all, I now had credit for 
three deliveries. Three more and I'd 
be in clover. 

Four days went by with only a few 
calls for false labor. At 2:00 AM on the 
tenth day, I got my call and delivered a 
child successfully, even though it was a 
very large one and took a lot of time 
and concentration. It was the first time 
I really felt that I had done something 
exceptionally well and totally on my 
own. I actually felt a little cocky about 
it, thus committing the age-old stu- 
dent's error of overestimating his level 
of expertise. I felt ready now and cer- 
tain that I'd not only get my quota but 
would probably be awarded the Croix 
de Guerre or something for excep- 
tional merit. Little did I know what 



was in store; 



That evening, my hopes for 
a quota success suffered 




a setback with the arrival of the other 
student. He had recovered from his 
intestinal flu and was ready to go. By 
^■^ . protocol, he was the one to get the 
next delivery as his instructional case 
with Van Etten, and we would alter- 
nate after that. I began to pray for 
multiple calls. 

Nothing happened. The twelfth 
and thirteenth days rolled by and all I 
could do was suffer in silence. At mid- 
night the phone rang and both of us 
jumped out of bed as though shot. I 
backed off when I realized it wasn't my 
turn and slumped dejectedly on my 
cot. It turned out to be a bona fide 
case, and in a matter of minutes. Van 
Etten and student Weston were gone. 

I got up and made a cup of coffee, 
which did little for my nerves, but at 
least filled some of the time. I paced 
around in complete frustration realiz- 
ing fill! well that I'd have to come 
back again, and could never erase the 
onus of failing to complete my six in 
one stint. 

In the depths of my despair, I 
didn't even register that the phone was 
ringing till the third ring. I came to 
with a start, and grabbed it off the 
hook. It was my fifth call, a true deliv- 
ery. I got things together and started 
off, but couldn't shake the bitter 
thought that it would do me no good, 
I still would be one short of my quota. 

As I approached the place, my bet- 
ter self took over. So be it. After all, I 
was here to learn, not to win contests. 
There was a woman waiting for me to 
give her solace and deliver her child. 

When I reached the address, it was 
a run-down tenement house, which 
looked like no one had done a thing to 




it for years. Trash littered the halls, 
and a bum was curled up in a drunken 
sleep inside the unlocked door. The 
place smelled like tobacco, garbage 
and rot. A radio was blaring some- 
where above, and sounds of scuffling 
and cursing almost drowned it out. I 
decided to get on with it and get it 
over. 

There was no need to knock: the 
door was open. I started to go in, but 
was almost bowled over by the rapid 
exodus of a huge orange striped cat 
trying to escape the open jaws of a 
mongrel dog. An empty can of beer 
followed the dog down the stairs, 
accompanied by a string of curses 
never meant for human ears. When I 
turned from the fleeing animals to see 
where the invective came from, I was 
confronted by a mountain of a man 
whose bared upper torso was com- 
pletely covered with hair. Out of red- 
dened eyes slitted in anger, he viewed 
me, his mouth still open like the smok- 
ing maw of a spent cannon. It was not 
surprising that he recovered his voice 
before I did. 

"Who the hell are you?" he asked, 
his voice reverberating like the base 
pipe of a cathedral organ someone had 
filled with gravel. 

I explained. He let this sink in for a 
moment, then grudgingly moved aside 
just enough to let me pass. "She's in 
there," he grumbled, raising a huge 
hairy arm and pointing toward a door- 
way in the back of the room. His 
words were punctuated by a loud 
scream from beyond the indicated 
door. 

He grimaced. "Just follow the 
noise, doc, you can't miss her." With 
this, he turned the radio on full blast 
and sank into a padded chair beside it. 
He never stirred from that spot for the 
rest of the time I was there, and paid 
no attention whatever to what ensued. 

I hesitantly entered the room and 
was greeted by another shrill scream. 
The light was very dim and I did not 
see her at first. When I did, I was 
shocked. She was squatting naked over 
a wash tub, which was partly filled 



with blood and amniotic fluid. 
Recovering quickly, I dropped my bags 
and went to her. With great difficulty I 
managed to get her to agree to go to 
the bed and lie crosswise on it, so that 
I could examine her. 

Fortunately, the light, such as it 
was, was behind me. I slipped on a pair 
of sterile gloves and proceeded to 
determine what the situation was. She 
was, as I had suspected, very close to 
delivery but there was no crowning 
yet. With luck I would be able to at 
least get some equipment ready if I 
hurried. 

I made it with plenty of time. 
Though she had another pain or two, 
there was no apparent change. I got 
out a clean drape, put her in delivery 
position, placed my instruments close 
by, and started talking to her as calmly 
as I could. When not in pain, she lis- 
tened intently and did what I asked of 
her. I was beginning to feel more con- 
fident and apparently so was she. 

When the next pain came, I told 
her to hold her breath and bear down. 
She did so all right, but with so much 
power that I had to caution her to go 
easy. She just couldn't help it. She 
bore down even harder. Then, to my 
startled chagrin, a sudden gush of 
blood appeared and behind it, some- 
thing else. I expected to see a head 
appear but alarmingly it was not a 
head, but an arm and hand! 

The first thing that went through 
my mind was the day in class when one 
of the first-year students had asked the 
question, "What do you do if the pre- 
senting part is an arm?" Professor 
Irving, despite his austere appearance, 
definitely retained his sense of humor. 
"Son," he said with a straight face, 
"The answer is very clear. You shake 
hands with the child, congratulate the 
mother, and run like hell for a doctor!" 

Fortunately, I also remembered the 
discussion that followed. Pulling on 
the arm would lead to disaster; not 
only a brachial plexus injury could 
occur, but also the head and body 
could well become jammed, making 
delivery almost impossible. 



Summer 1995 



31 



By this time the spasm was over, 
and the mother managed to relax. I 
knew it wouldn't last long, so I went to 
work as fast as I could. Gently I tried 
to replace the arm, and at the same 
time felt the position of the head. I was 
fortunate indeed, because the pressure 
of my manipulation suddenly caused 
the arm to reposition itself and the 
head swung into proper alignment. 
Though I didn't think of it at the 
moment, it was undoubtedly the small 
size of the infant and the mother's 
multiparity that were far more impor- 
tant than anything I did. 

The next contraction delivered the 
head, and with gentle assistance from 
me the baby was born. I grasped her 
tiny ankles and inverted her, patting 
her back. The cry of life filled the 
room. I cannot tell you how I felt at 
that moment, but it was an exaltation 
beyond anything I had ever experi- 
enced. I hardly remember severing the 
cord, or cleaning the child and hand- 
ing her, warmly covered, to the 
mother. When that had been accom- 
plished, I just sat there soaking in the 
music of her soothing words and the 
infant's lusty cries. 

After a moment, I automatically 
checked the fundus above, and then 
the introitus for laceration or bleeding. 
Everything seemed okay except that 
the fundus was still quite high and 
firm. I put gentle pressure on it for a 
while to ensure against it filling with 
blood, but after lo minutes or so, I 
could detect no change. Satisfied for 
the moment, I got up, took my instru- 



ments and threw them into the cloth 
sack we carried for that purpose, and 
stowed them in my bag. I took off my 
gloves and threw them in the waste bin 
in the small kitchen. All that remained 
to do was wait for the afterbirth, 
instruct the mother and father on how 
to care for the baby, and leave. 

I turned back to check again just to 
be double sure, and was greeted by a 
cry of pain. The mother was throwing 
her head fi-om side to side, her eyes 
filled with fear. "Something's happen- 
ing!" she cried in panic. 

I calmly reassured her. "It's all 
right," I said softly, "it's only the after- 
birth. Don't worry." 

I laid my hand on her abdomen. 
The fundus was much smaller. I 

I looked below, expecting to see the 
placenta. What greeted my eyes put 
me in a temporary state of shock. 
There, presenting at the introitus, was 
not the placenta but another head! 

When I got myself under control, I 
reached for some gloves, but there 
were none. I had used them up, not 
expecting anything like this to happen. 
All my equipment was dirty and 
stowed away. All I could do was go 
ahead as I was and get the baby born. 

I reached up and put some pressure 
on the fundus. To my surprise and joy, 
the baby slipped out and almost imme- 
diately began to gasp and cry. I found 
a sterile hgature in a glass vial, broke it 
and tied the cord. I hesitated to cut the 
cord with unsterile scissors, but rea- 
soned that the area was already conta- 
minated. I then covered the umbilical 



area with a sterile gauze pad, placed 
the tiny infant in a clean towel, and 
gave him to the mother. 

She appeared totally confused, 
looking from one bundle to the other 
without understanding. It dawned on 
me that so shocked had I been at this 
whole unexpected turn of events that I 
had completely forgotten to inform 
her of her "second coming" until it 
was a fait accompli. While I was trying 
to adjust to this new dilemma, she 
stared at me at me in wide-eyed bewil- 
derment. I had to come up with some- 
thing. 

"Well!" I said, trying to act as 
though this were an everyday event, 
"It looks like you got yourself a 
bonus!" 

"A what?" 

"A bonus, you know, an extra gift 
from God." She still looked blank. I 
smiled. "You, madam, are the mother 
of twins! One girl and one boy. What 
more could you ask?" 

Her first reaction starded me. She 
stared at the second bundle in silence, 
then turned to me anxiously. "What 
am I going to name it? I never planned 
on two. I just knew I'd have a girl, my 
horoscope said so, so I had a name all 
picked: Bonnie!" She glanced at the 
tiny baby boy again, contemplatively, 
then back at me. "What was it you said 
I had?" she asked. 

I chuckled in relief that she hadn't 
turned on me. "First a girl, then a 
boy," I replied. 

"No, I mean, you called it some- 
diing." 




32 



Harvard Medical Alumni Bulletin 




Illustrations by Manuel King 



Suddenly I realized what it was she 
wanted. "Bonus, yes, I said you got a 
bonus." 

"That's the word. It means 'An 
extra gift from God' — isn't that what 
you said?" 

I nodded. 

She smiled confidently. "That's it 
then. His name will be Bonus! Bonnie 
and Bonus Brezinski!" She beamed 
with parental pride. 

I tried unsuccessfiilly to get my 
mouth closed. 

It is almost anticlimactic to say that 
I had, by virtue of that double delivery, 
made my quota and thus assured 
myself of the respect of my peers. On 
top of that, I had also gained a mea- 
sure of fame because not only had I 
delivered an arm presentation success- 
fully, but I was the only student any- 
one could remember who had 
delivered, all by himself, a set of twins. 

Now, many years later, I still think 
of those exciting and enlightening 
times with a glow of pleasure and, in 
reflective moments, ruminate over 
what might have happened to my six 
children. It may be just as well that I'll 
never know, but I still can't help won- 
dering about them. 



James Locke Neller '39 was a practicing 
surgeon in Los Angeles for nearly ^0 
years, serving as chief of staff or chief of 
surgery at various times for three of the 
area^s hospitals. In retirement now, he is 
busily engaged in writing, gardening and 
enjoying his family. 



Especially Bonus. ^ 



Summer 1995 



33 




The 
Old 
Chief 



Frederick C. Irving 



Reprinted from Safe Deliverance by 
Frederick C. Irving, Houghton Mifflin 
Co., 1942. 



.jj photo courtesy of Rare Books, Countway 
Library 



34 



Harvard Medical Alumni Bulletin 



In the history of every hospital that is old enough 
to have traditions there is always one name endowed with a 
special and particular luster, whose mention will conjure up 
visions of the brave old days and recall the achievements of 
the past. At the Hotel Dieu it is Dupuytren; at Guy's it is 
Sir Astley Cooper, who lies buried in its chapel. The leg- 
endary figure of the Massachusetts General Hospital is 
Henry J. Bigelow — that brilliant, skillful, imaginative, and 
flashy Bostonian with the full beard — who each morning 
drove down Beacon Street in his dashing cabriolet. His 
high-stepping horse, jingling its monogrammed harness — to 
say nothing of Bigelow himself — filled the eyes of the 
dwellers on that thoroughfare in a most unaccustomed fash- 
ion. 'This' thought they, 'in a common person would be 
ostentatious vulgarity, but since he is a Bigelow it can only 
spring from vitality and exuberance.' Bigelow was not only 
the surgical tsar of Boston in his day, but he had a finger in 
everything, medical or otherwise, into which he could insert 
it. He was an Elizabethan, born out of his time and place, 
but completely uninhibited by such a handicap. 

In appearance, personality, and character Richardson was 
no such arresting figure as Bigelow, but nonetheless he is 
firmly enshrined at the Boston Lying-in Hospital as its 
patron saint. He was a slight man of no more than medium 
height, with a high and prominent forehead, a long and 
slightly concave nose, and a mustache of the pseudo-handle- 
bar or quasi-walrus type. He had lost his left eye from an 
infection acquired in his early days when attending a septic 
case (the same disaster had befallen the nurse who had 
assisted him). In its place he wore a glass substitute, which, 
fixed unwinkingly upon a delinquent student summoned 
before him in his capacity as dean of the Medical School, 
would fill the young man with foreboding; and even after 
the culprit had departed its presentiment would pursue him 
during his waking and sleeping hours. All pictures of Dr. 
Richardson show only his right profile — except his portrait 
in the faculty room of the Medical School, in which the 
artist has painted his full face but with his left eye in the 
shadow. Legend has it that the power of his single eye was 
uncannily acute; certainly monocular vision imposed no 
handicap upon him as a practitioner, nor did he ever fail to 
see what went on about him. 

With younger doctors and students he sometimes 
appeared abrupt and reticent, but closer acquaintance 
always revealed him as kind, cheerful, and optimistic. His 
patients, both in the hospital and in private practice, adored 
him. Devoid of good looks, great charm of manner, or any 
of the accepted equipment for enchantment, he could influ- 
ence women with no effort at all, probably because he 
inspired them to trust him. He even persuaded certain 
elderly and highly respectable spinsters, whose interest in 
illegitimacy must have been only of a speculative nature and 
whose knowledge of the reproductive function could have 
been no more than academic, to give large sums of money 



to the hospital for the care of unfortunate and 'fallen' 
women. 

William Lambert Richardson was born in Boston in 
1842, received his A.B. and M.A. degrees from Harvard 
College, and his M.D. degree from Harvard Medical 
School. He was thus a young man of military age at the time 
of the Civil War, but the conflict seems to have affected 
him little — certainly not to the extent of leading him into 
the Union Army. This is not surprising, for there were, like 
Richardson, a number of well-born young Bostonians who 
did not approve of the war and showed their disapproval by 
ignoring it. In 1868 he studied in Vienna and Dublin, and 
returning to Boston he was at once appointed to the staffs of 
the Massachusetts General Hospital, the Children's 
Hospital, and the Boston Dispensary. Trained medically 
rather than surgically, he practiced internal medicine as well 
as obstetrics all his professional life. Not only did he possess 
unusual diagnostic skill, but in certain of the manipulative 
procedures in operative delivery — notably in internal 
podalic version — he developed the dexterity of a virtuoso. 
He wrote an article upon manual dilatation of the cervix, a 
method of forced delivery, which probably did more harm 
than good; for it encouraged others less skillful to undertake 
a maneuver which even in Dr. Richardson's hands was 
sometimes followed by laceration, shock, and hemorrhage 
in the mother and death or irreparable damage to the baby. 

Dr. Richardson was instructor in obstetrics at Harvard 
Medical School from 1871 to 1872, and again after the 
reopening of the hospital, from 1874 to 1882. Charles E. 
Buckingham, who, it will be remembered, succeeded D. 
Humphreys Storer in 1869 as professor of obstetrics, and 
John P. Reynolds, who followed Buckingham in 1877, were 
consulting physicians at the hospital; but they took no active 
part in its operation, nor were they often asked to give 
advice. Dr. Richardson became assistant professor in 1882 
and was elevated to the rank of professor in 1886, occupying 
the chair until he retired in 1907. Like Channing and 
Humphreys Storer, he was dean of the Medical School, and 
later also dean of the faculty of medicine. 

In 1880 Dr. Richardson established an out-patient 
department at the Boston Lying-in Hospital to provide free 
care in childbirth and the puerperium for poor women in 
their homes. Medical students were to supply this care 
under the immediate direction of the house officers, who in 
complicated cases were to call in members of the visiting 
staff. Although during the next year only seven patients 
were delivered on the district thus established, by 1892 the 
annual number had risen to over a thousand and to over two 
thousand by 1907, the year that Dr. Richardson retired. 
The project was later taken over by Dr. Charles M. Green 
who gave a summer course to second-year students. The 
admission by Dr. Richardson of students to the hospital 
wards in 1883 marked the beginning of the first teaching 
obstetrical clinic in New England. 



Summer 1995 



35 



Dr. Richardson was one of the ablest medical teachers of 
his time. Always forceful and dramatic, he had been during 
his undergraduate days at Har\^ard a star in the Hasty 
Pudding" plays, and his lectures revealed the talents of a 
born actor. So deeply imbued was he with the spirit of the 
theater that when the Medical School in 1906 moved to its 
new buildings on Longwood Avenue he declined to lecture, 
like the other professors, in the pit of an amphitheater, and 
he was given a special room with a stage from which he 
might look down upon his students as he paced back and 
forth. Nothing was lacking but footlights and scenery; but 
'Billy,' as the students called him, needed neither to create 
the proper illusion when describing some great crisis in 
obstetrics. In depicting the delivery of a woman with pla- 
centa praevia, he would remove his coat, roll up his sleeves, 
and demonstrate with deft motions how one dilated the 
cervix manually, performed internal podalic version, and 
delivered the baby. 

In his lectures, as in his conduct of the hospital, Billy was 
no innovator; in fact certain uncharitable persons said that 
he gave exactly the same lectures in 1907 as in 1886, a state- 
ment which is undoubtedly an exaggeration. Be that as it 
may he taught obstetrics as he knew it with great conviction 
and vigor; there were no 'ifs' and 'buts' in his lectures. 

On one occasion he informed his class that no baby had 
ever been born that weighed more than fourteen pounds. 

'How do I know this?' he asked his pupils, fixing them 
menacingly with his one good eye. 

They regarded him expectantly, for they knew the 
answer would be forthcoming and that it would be authori- 
tative. After the proper dramatic pause he announced, 
'Because in all my experience I have never seen a baby that 
weighed more than fourteen pounds!' 

The class settled back in its seats, convinced that the top 
weight of large babies had been settled for all time. When, 
several days later, the hour for the next lecture arrived, they 
were startled to see him stalk in, followed by a house officer 
from the Lying-in Hospital who bore in his arms a large 
squirming bundle wrapped in a blanket. Dr. Richardson 
turned and faced the class. 

'Gentlemen,' said he, 'I am a liar! How do I know that I 
am a liar?' 

Again a pause for just the proper number of seconds. 

'Because here is a baby that weighs fourteen pounds and 
two ounces.' 

He pointed to the house officer, who opened the blanket 
and disclosed an infant, large enough to be at least three 
months old, which at that moment began to bellow rau- 
cously. 

Not only did Dr. Richardson undertake with enthusiasm 
the teaching of students, but he began a systematic course of 
instruction for nurses at the hospital. The organization of 
the training school was his project, and he developed it with 
his usual thoroughness. On several previous occasions he 



had sent nurses to the Massachusetts General Hospital to 
give instructions in the bathing of infants. Following one of 
these demonstrations he told Mrs. Higgins, the matron, that 
the baby behaved beautifully and, said he, 'The nurse did 
well, too.' 

Dr. Richardson made no original contributions to 
obstetrics, for he clung by habit to the principles and meth- 
ods that he knew; he had none of the speculative curiosity 
that leads one to wonder how the cogs and levers of the 
human machine work. Although he himself was a conserva- 
tive, once he was convinced that new ideas had merit he 
encouraged his younger staff to put them into practice. 
Assured of the value of antiseptic methods in the prevention 
of puerperal fever by the work of one of his house officers 
done, incidentally, against his orders — he established them 
in the hospital and wrote a classic monograph upon the 
results; impressed by the benefits in certain cases of pelvic 
obstruction to mother and child from Cesarean section, he 
encouraged George Haven and Edward Reynolds to per- 
form them and he reported with enthusiasm their favorable 
results to the trustees, although during his whole profes- 
sional life he himself never attempted an abdominal opera- 
tion. His fame, however, will always be secure because he 
resuscitated the dormant hospital, transfused it with the 
vital fluid of his own optimism, and nursed it carefully until 
it could stand squarely upon its own feet, where today it is 
securely planted. David Cheever says of him, 'He made this 
hospital one of the great institutions of its kind in the 
world.' 

In the early days of 24 McLean Street Dr. Richardson 
worked in the little garden behind the house, and on occa- 
sions he helped Mrs. Higgins, the matron, to stir her cele- 
brated plum puddings. Of greater benefit, however, were 
his periodic forays upon the golden galleons of State Street. 
He was the son of a Boston banker and wealthy himself, his 
friends were men of substance, their wives were his patients, 
and he knew where the treasure lay and how to extract a 
tithe for the charity he loved so well. Possibly his success 
was due in some part to the conviction carried by his own 
generosity, for from time to time he made the hospital gifts. 
He once installed new electric wiring at his own expense in 
the McLean Street building, and after it was decided to 
move to Longwood Avenue, across the street from Harvard 
Medical School, he gave over half of the ninety thousand 
dollars needed for the purchase of the land. When in 1932 
he died a widower and without children, he left the bulk of 
his fortune so that it would come eventually to the hospital 
and to the Harvard Medical School. ^ 

Frederick C. h'ving ''10 was the legeitdary chief of obstetrics at the 
Boston Lying-in and the HMS William hamhert Richardson 
Professor of Obstetrics from ig^i to 194']. 



36 



Harvard Medical Alumni Bulletin 



For Better or For Worse 



by Thomas H. Coleman 



My uncle, Jerome Head '23, was 
one of the first surgeons to open a live 
patient's chest. He became a respected 
surgeon in Chicago, a student of 
tuberculosis, and the father of six sons, 
four of them doctors. He told me this 
story. 

In 1923 he was fortunate enough to 
be accepted as one of Harvey 
Cushing's interns in surgery at the 
Peter Bent Brigham. Gushing believed 
that surgical skills and practice were 
best learned in an atmosphere of undi- 
vided loyalty without unnecessary dis- 
tractions. He had an absolute rule that 
no intern or resident on his service 
could be married. 

One weekend Jerome took two 
days off to marry my wonderful Aunt 
Jean, a nurse at Children's Hospital. A 
few months later their secret was 
betrayed by someone who noticed that 
"Miss Milne" was securing the back of 
her apron with rubber bands. Through 
whispers and an intricate grapevine the 
news eventually came to Cushing. 

One morning the resident in 
surgery came to Jerome with the mes- 
sage that Cushing wanted to see him 
that afternoon in the board room of 
the hospital. Jerome had a pretty good 
idea of the reason and spent the next 
few hours with depressing and anxious 
thoughts about his future, knowing he 
was about to be fired out of the best 
internship anyone could hope to have. 

With a dry mouth and a low state 
of mind, he entered the room to face 
Cushing, who sat on the opposite side 
of the table with the chief resident and 
the hospital administrator. Jerome 
remained standing and was not invited 
to a chair, which gave the scene the 
merciless air of a court-martial. 

They all had a go at him. Didn't he 



know the rules? Why did he think he 
was an exception? Didn't he realize 
this would distract him from the 
responsibilities of his internship? 
Jerome's memory of the experience 
was that as he stood there hearing 
those unanswerable questions, he 
slowly regressed to the shame and 
despair of a young son before a scold- 
ing father. 

When Cushing had finished with 
him and said, "Well, Head, have you 
anj^hing to say?" Jerome responded in 
a way he might have when he was only 
1 2 years old: "No sir, except that I am 
very sorry and I won't let it happen 
again." 



His other two inquisitors laughed 
out loud. Cushing didn't laugh, nor 
did he fire young Dr. Head. At the end 
of the internship in November Jerome 
wrote Cushing a note of appreciation. 
He answered: "Dear Head, I'm glad 
you feel that way. We will all expect 
great things of you for your sake, and 
our own. Give my regards to your 
wife. I wish I could have seen her 
again. She will keep you up to the 
mark. Always yours, Harvey Cushing." 

Thomas H. Coleman '.^^ is an internist in 
Denver. 




Summer 1995 



37 









i^mid 



Countway's 
Biographical Sleuths 



by Ellen Bm4ow 



38 



Harvard Medical Alumni Bulletin 






Lurking around every corner, 
piled in aisle after aisle, are James 
Jackson Putnam, Oliver Wendell 
Holmes, Hans Zinsser, Walter B. 
Cannon, Edward Churchill, Paul 
Dudley White, Fuller Albright, 
Stanley Cobb and legions more 
Harvard legends. Spend enough time 
in Rare Books at the Countway and 
you will hear them talking. 

Dick Wolfe, curator of rare books 
and manuscripts, his wife Elin, associ- 
ate curator of manuscripts and 
archives, and their staff of six could be 



kept busy for the next century organiz- 
ing and cataloguing the papers left to 
the library by famous faculty and 
alumni. From some people, they have 
three or four boxes of letters, files, 
patient notations — papers accumulated 
throughout professional careers. In 
one of their most extensive collec- 
tions — on Clarence Gamble '20 and 
his work in the birth control move- 
ment — they have 266 boxes holding 
over 100,000 pieces that have been 
read, labeled, individually placed in 
acid-free folders, and organized in 



boxes labeled with contents. 

"Letters tell the background; 
they're where what was really going on 
emerges," says Dick Wolfe, who him- 
self has published extensively on a 
diverse range of historical subjects. "In 
them you can get a sense of all the 
interlocking or fighting personalities. 
You don't find that in their published 
works." 

For anyone writing a biography, 
giving a speech, or writing an article 
on an incident from medical history, 
these papers — plus the unsurpassed 



Summer 1995 



39 



collection of rare books and manu- 
scripts — are an El Dorado of opportu- 
nity. They are a never-ending source 
of biographies waiting to be written. 

There are boxes of materials by 
members of the Harvard medical 
dynasties: the Shattucks, Warrens, 
Channings, Bowditches. There are 
records of the Massachusetts Medical 
Society from before 1851 to 1971; the 
post- WWII papers of George and Olive 
Smith, including their research on 
DES, which turned out later to be a 
horror rather than a help for miscarry- 
ing women. There are the patient 
records of Eugene Emerson, a psy- 
chologist at Mass. General Hospital 
and Mass. Mental Health Center who 
took over the patients of James 
Jackson Putnam. (Elin Wolfe calls this 
"One of the richest mental health col- 
lections of its kind.") 

Physicians with a desire to keep a 
mentor or friend's memory alive, 
scholars, journalists and medical histo- 
rians call and come in all the time to 
use these collections. About half of the 
Countway Library houses historical 
materials, which are the basis of its 
world-class status. 

To write a biography or recon- 
struct history, the Wolfes are strong 
believers in hands-on scholarship. 
Browsing is essential to allow for 
serendipity, they contend. "You have 
to live with this stuff," says Dick 
Wolfe. "If you want to research a sub- 
ject, you have to be like a shoe-leather 
epidemiologist — always reading, 
always collecting." 

There is a physician from 
Tennessee sitting at a table, sur- 
rounded by boxes filled with materials 
from the Thorndike Laboratory by 
Bill Castle '21. He's working on his 
second draft of a biography and Dick 
Wolfe, who has been curator here for 
3 years, is telling him stories about 
Castle, pulling out other materials as 
they occur to him. As Wolfe says later, 
"You read these things and you can 
hear Bill Castle talking." 

Wolfe knows where everything is — 
even the uncatalogued — because he 



"When a person lives 
and does things^ it 
always involves 
others^ which creates 
a lot of dust. " 



has literally carried all of it to where it 
now rests, after sifting through papers 
and transporting them from the bene- 
factor's house or office. But even he 
finds things he never saw before or 
that pique his interest when he pulls 
out a box for someone else. "I start 
files and drop pieces in until someday I 
write something up," he says. He gets 
up every morning to write and has 
three or four projects going at once. 

He just finished, for example, a 
lengthy article on John Dean, the first 
physician to do neuroanatomy 
research in the United States in the 
mid-nineteenth century. When he first 
started his research on Dean, all he 
had was a one-page obituary. That led 
to correspondence that he found at the 
Smithsonian. Then he came across a 
book by Dean from 1863 that had 
anatomical photos Dean had taken, 
such as of a cross section of the 
medulla — perhaps the first book with 
medical photography. From the single 
original page, Wolfe eventually wrote 
120. 

"When a person lives and does 
things, it always involves others, which 
creates a lot of dust," he says. "When 
the dust settles, you can recreate what 
went on. If you can find enough 
records, you can reconstruct from 
ashes." 

He has written several books that 
each took a decade or longer to com- 
plete because there was not much 
material on their subjects: one on the 
historic rise and fall of the craft of 
marbled paper (Wolfe is a marbler 



himself) and the other on music 
engraving and publishing. Detective 
work to dig up information for these 
books took him to libraries across 
Europe. 

Sometimes an article or book 
emanates from a forgotten footnote to 
history. Eli Chernin, a professor of 
tropical public health who started 
writing late in his career, wrote many 
fine medical history articles, says 
Wolfe. One was a definitive paper on 
Richard P. Strong and the Manchurian 
plague. When looking through Strong 
materials, Chernin discovered an inci- 
dent that no one talks about today, 
although there was a pubHc health 
investigation at the time: when Strong 
was experimenting on prisoners, some- 
one switched vials and he unintention- 
ally gave smallpox to his subjects. 

Though obsessed is not the word 
Wolfe would use to describe how 
caught up you can get with the people 
you are researching, he does acknowl- 
edge that your subjects become your 
friends or your enemies whom you live 
with all the time. 

"Of course, you try to get inside 
their heads and they certainly get 
inside yours," says Elin Wolfe, who is 
co-author with Cliff Barger '43A and 
Saul Benison of Walter' B. Cannon: The 
Life and Times of a Young Scientist 
(Harvard University Press, 1987). She 
would find herself in conversation with 
her teenagers saying something like, 
"Well, in the case of Cannon..." and 
they'd groan. She was contracted to 
catalogue the Cannon papers in 1978 
after completing several other major 
collections (at the time, she was not 
working full time in Rare Books) and 
Barger and Benison were so pleased 
wdth her results that they asked her to 
stay on the project as a co-author. 
They are now working on volume 
two. 

So many collections remain uncata- 
logued because it takes time and 
money. "It's a very labor intensive 
activity," says Elin Wolfe, "but then so 
is scholarship. Learning is labor inten- 
sive." With the trend in libraries now 



40 



Harvard Medical Alumni Bulletin 



People write medical 
biographies out of 
respect or affection 
for their subject^ and 
certainly not for the 
money. 



to store materials off-site with only a 
bar code on the box, she is concerned 
that "no one is going to know the trea- 
sures lurking in that box." With on- 
line computer cataloguing, there is a 
further distancing of scholars from the 
people who can help them find what's 
in the box. 

They preserve these papers, 
because as Dick Wolfe says, "If we 
don't, who else will?" It's the same 
reason people write medical biogra- 
phies — out of respect or affection for 
their subject, and certainly not for the 
money. 

As for the actual writing of a book, 
Wolfe reveals what he believes are the 
three critical ingredients: you have to 
know something, be able to express it, 
and organize it. "Many people can do 
the first two, but few can do the third 
well." You need to be more than a 
good storyteller, he says. The book 
can't plod along; it should "want to be 
read." 

There are academic presses that 
publish medical biographies but, he 
says, because they typically don't sell 
well, they're very difficult to get 
accepted. This is why he started 
Countway Library Publications in 
1972 with a small fund of money to 
which the authors can contribute. 
They have published such medical 
biographies or histories as Benjamin 
V. White's '34 book on Stanley Cobb 
'14, Oglesby Paul's '42 books on Paul 
Dudley White '11 (1986) and on 



Francis Weld Peabody '07 (1991), 
Gordon Scannell's '40 account of 
Edward D. Churchill '20 on his 
Moselely Traveling Fellowship (1990), 
and Carleton Chapman's '41 on John 
Shaw Billings (1994). 

Often Dick Wolfe advises people 
writing biographies to tape interviews 
with people who knew their subject. 
These oral histories then become part 
of the archives. In fact, in part because 
people aren't saving their papers as 
much these days, an oral history pro- 
ject — initiated by Arthur K. Solomon 
(professor of biophysics emeritus) — is, 
as Wolfe puts it, "getting them while 
they're alive." So far they have tapes 
and bound transcriptions of interviews 
with John Edsall '28, Francis D. 
Moore '39, George Thorn and 
Seymour Kety. 

It's crowded on the three half- 
floors that Rare Books occupies in 
Countway, in more ways than physi- 
cally. There are thousands of people 
from the past, patiently waiting for 
someone to listen to them once again. 

Ellen Barlow is editor of the Bulletin. 



Summer 1995 



41 




i 



Serendipity and the Career 



by Franklin H. Epstein 



42 



Harvard Medical Alumni Bulletin 



The first Harvard professor of 
medicine at Beth Israel Hospital was 
Herrman Ludwig Blumgart '2 1 . More 
than any other person he was responsi- 
ble for establishing that institution as a 
major academic hospital at Harvard 
Medical School. 

Most illustrious careers are shaped 
in part by one or more happy acci- 
dents, and Blumgart's was no excep- 
tion. The term serendipity has been 
used to describe this phenomenon. It 
derives from the story by Horace 
Walpole of the three princes of the 
imaginary country of Serendip, who 
were subject to the most amazing acci- 
dents that always turned out for the 
best. It is interesting to trace the role 
of serendipity in Blumgart's own 
career. 

He was born in Newark, New 
Jersey in 1895, the last of four children 
of Albert and Sophie Blumgart who 
had come to America from Harburg in 
Bavaria. His father, a gentle, rather 
easygoing man, was a butcher who ran 
a grocery store. Sophie was the strong 
one in the family, determined that her 
children should succeed. They were 
not religious Jews; none of the three 
boys became a bar mitzvah and 
German, not Yiddish, was spoken in 
the home. (Towards the end of his life, 
after Blumgart had a stroke that left 
him aphasic, the first words that came 
back were German.) 

The oldest brother, 1 5 years older 
than Herrman, was Leonard Blumgart. 
After leaving high school in Newark, 
Leonard was admitted to Columbia 
College of Physicians and Surgeons (in 
those days college was not required). 
He became a psychiatrist, was one of 
the first to be analyzed by Freud, and 
later helped to found the New York 
School of Psychoanalysis. In many 



ways he was like a parent to Herrman, 
who was the baby of the family. 
Herrman helped in his father's store 
and went to public school in Newark, 
where he excelled. Upon graduation 
he received a full scholarship to 
Lafayette College in Pennsylvania as 
well as a partial scholarship to 
Harvard; he enrolled at Lafayette 
because the scholarship paid more. 

During his first year at Lafayette, 
the first of many happy accidents befell 
him. He was absolutely miserable. He 
was taunted for being Jewish and was 
hazed unmercifully by upperclassmen. 
On his brother's advice, he applied for 
admission to Harvard in the sopho- 
more year and was able to take advan- 
tage of the partial scholarship 
previously offered. He made up the 
rest of the necessary money by work- 
ing during his vacations at his Uncle 
Louie's clothing business in New York 
City. 

At first he wanted to be a business- 
man like his uncle. But he was influ- 
enced at Harvard by a charismatic 
professor of psychology, Ned Holt, 
under whose spell Walter Lippman 
also fell. It was not hard for Blumgart 
to decide, given the example and 
encouragement of his brother, to go 
into medicine. His record was good 
enough that he was offered a place in 
the Harvard Medical School class at 
the end of his junior year. But his 
mother insisted that he complete the 
entire course at Harvard before going 
to medical school — she wanted him to 
have that Harvard degree. 

In 191 7, when Blumgart entered 
HMS, the curriculum had undergone 
some recent changes. As originally 
urged by Harvard's famous president, 
Charles Eliot, the case method was 
increasingly being used in the preclini- 



cal years to teach basic sciences. David 
Edsall, newly appointed dean, had 
worked to modify the curriculum to 
free it fi-om rigid requirements. He 
wanted to "provide an opportunity for 
students of superior capacity to go 
beyond the routine requirements and 
get a somewhat more advanced and 
scholarly development." Back in the 
early years of this century, these ideas 
were referred to by some as a "New 
Pathway." 

In his first month as a freshman, 
when the head and neck were being 
taken up in anatomy, Blumgart had the 
temerity to dress up in surgical cap and 
gown, scrub up, and approach the emi- 
nent Harvey Gushing, who was oper- 
ating on a series of brain tumors in the 
surgical amphitheater at the Peter 
Bent Brigham Hospital. Assuming he 
was a resident. Gushing immediately 
directed a string of peremptory ques- 
tions at him and reduced Blumgart to 
an embarrassed stammer. "I'm sorry, 
sir; I'm just a freshman medical stu- 
dent." 

Without breaking his stride, 
Gushing commanded his diener to 
bring a copy of Gray'' s Anatomy and set 
it on the stand. Gushing then pro- 
ceeded to instruct the awed freshman 
in surgical details of craniotomy. 
Blumgart often quoted this incident in 
later life as an example of the art of 
teaching, but this serendipitous expo- 
sure to surgery so frightened him that 
he decided to go into psychiatry. 

He was dissuaded from that course 
by another happy accident. In his 
senior year, thanks to the new curricu- 
lum, he was able to work with Cecil 
Drinker and Francis Weld Peabody in 
Walter Gannon's Department of 
Physiology. Peabody, the young, 
charismatic star at the medical school 



of Herrman Blumgart 



Summer 1995 



43 



whom everyone adored, was a Boston 
Brahmin with brains and charm. 
Drinker was interested in the effect of 
pidmonary congestion on gas 
exchange and vital capacity in the 
lungs of experimental animals. 
Drinker, Peabody and Blumgart col- 
laborated on a substantial paper 
describing this work. What's more, 
Blumgart had gained the friendship 
and respect of two men who would 
help him in his future career. 

In 192 1 Bluingart graduated from 
HMS. William B. Castle was in his 
class, as was Tracy Mallory, the 
famous pathologist. Of the 60 or so 
class members listed in his yearbook, 
most were identified by a nickname: 
Bill, Chip, Chuck, Shorty. In the entry 
for Herrman Ludwig Blumgart there 
is no nickname. 

Against the advice of an assistant 
dean, he applied to the Massachusetts 
General Hospital and to the Peter 
Bent Brigham for an internship in 
medicine. The advisor convinced him 
to withdraw his application to the MGH 
because it would only lead to embar- 
rassment for a Jewish candidate, but 
Blumgart refused to withdraw his 
application to the Brigham. Henry 
Christian accepted him as the last of 
nine interns. 

The full-time staff at the Peter 
Bent Brigham Hospital in 192 1 con- 
sisted of Christian as physician-in- 
chief; Charming Frothingham, another 
eminent academic internist; Cyrus 
Sturgis, the chief resident who later 
became the powerful and autocratic 
chief of medicine at the University of 
Michigan; and nine house officers. 
Among the eight part-time faculty was 
George Richards Minot, later to win 
the Nobel Prize for discovering the 
liver treatment of pernicious anemia. 
Francis Peabody was nominally at the 
Brigham, but in 192 1 was on sabbatical 
leave at the Peking Union Medical 
College in China. 

Interns were on call every other 
night and every other weekend. They 
were unmarried and lived in the hospi- 
tal. There were no intensive care units, 




Department of Medicine at Betli Israel Hospital at the first of what came to be an annual dinner, Harvard Club 1930. 
Blumgart is seated at the head of the table wHh Many Linenthal, physician-in-chief, to his right. Samuel Levine is the 
last person seated to the extreme right of the photo. 



and if a patient was on the danger list, 
the intern was not supposed to leave 
the hospital. On the other hand, the 
length of stay averaged 14 days and by 
today's standards, the pace and the 
number of patients admitted and 
worked up per day was slow. 

We hear a lot about the iron men 
of yesteryear, but an inspection of the 
medical records of the Peter Bent 
Brigham Hospital (all still stored in a 
warehouse in New Hampshire) reveals 
that in the sample week of November 
28, 1 92 1 there were 50 admissions. 
With nine house staff, this works out 
to five or six admissions per intern per 
week. What made it even easier was 
that 20 of those 50 had the admitting 
diagnosis of syphilis and were routine 
admissions for intravenous arsenic 
therapy. Five admissions during that 
week had pharyngitis or pneumonia. 
Two had diabetes mellitus, difficult to 
treat in those days as insulin was not 
yet commercially available. Three had 
heart disease, two had mitral stenosis 
and one had what was called chronic 
myocarditis. 

One of the 50 admissions turned 
out to be another serendipitous occur- 
rence in the career of Herrman 
Blumgart: a fascinating patient who 



became the subject of a well written 
paper that would gain young Blumgart 
deserved praise. The patient was a 16- 
year-old schoolboy from Medford with 
diabetes insipidus caused by congenital 
syphilis, an unusual event even when 
syphilis was a more common disease 
than it is today. 

By 1920 it was known that poste- 
rior pituitary extract would reduce 
polyuria in cases of diabetes insipidus. 
A commercial preparation ("obstetrical 
Pituitrin") was used in obstetrics for 
another purpose: to contract the 
uterus after delivery. For an antidi- 
uretic effect, injections had to be given 
subcutaneously every few hours, how- 
ever, and the treatment was not 
thought to be practical. The extract 
was ineffective when taken orally. 

In a meticulous piece of clinical 
investigation that would do credit to a 
modern clinical research center, the 
26-year-old intern demonstrated 
unequivocally that when obstetrical 
Pituitrin was sprayed into the nose it 
had an antidiuretic effect entirely com- 
parable to subcutaneous injection, 
though larger quantities were required 
to produce the same effect. No antidi- 
uresis was seen when pituitrin was 
retained in the mouth for 10 minutes 



44 



Harvard Medical Alumni Bulletin 



and then swallowed, or when it was 
given by rectum. An interesting fea- 
ture of the original hospital record, 
not reported in the final paper, is that 
Blumgart tried injecting normal cere- 
brospinal fluid intravenously, presum- 
ably in the hope that antidiuretic 
hormone might be present in high 
concentration in the cerebrospinal 
fluid. No effect was obtained. 

Blumgart published these results in 
the Archives of Internal Medicine early 
the following year in 1922. It was, of 
course, the first description of what 
was to become the standard treatment 
of such patients. George Minot wrote 
to him, "This manuscript is truly 
excellent. It demonstrates splendid 
clinical observations of the highest 
order. I consider this work of yours a 
true monument to Harvard medicine." 

Why did young Blumgart think of 
putting pituitary extract into the nose? 
There are two hints in the original 
Archives article, contained in 
Blumgart's meticulous footnotes. The 
first mentions that Peabody, with 
whom he had worked in Drinker's lab- 
oratory, had earlier studied polio virus 
at the Rockefeller Institute and 
thought that the virus gained access to 
the central nervous system from the 
nose via lymohatics leading directly 
from the upper nasal passages to a sub- 
arachnoid space. The second note is a 
personal communication from Otto 
Schloss, a professor of pediatrics at 
Children's Hospital at that time, who 
made rounds at the Brigham and who 
must have dispensed his clinical pearls 
on infectious disease to the interns 
there, including Blumgart. One of 
them was: "Clinically, in children, a 
surprisingly small patch of inflamma- 
tion in the nasopharynx excites convul- 
sions, stupor, and other phenomena 
indicative of considerable cerebral irri- 
tation." 

Blumgart described another patient 
seen during his internship in a paper 
that achieved less fame but is just as 
interesting. A 3 2 -year-old man had 
developed profuse fatty diarrhea, 
weight loss and tetany. He died in 



But for serendipity^ 
Blumgart might 
well have specialized 
in disorders of salt 
andwater^ in 
endocrinology^ or in 
gastroenterology. 



extreme cachexia and at postmortem 
the abdominal lymph nodes and spleen 
were found to be enlarged. Phagocytes 
with foamy reticulated cytoplasm were 
found in the lymph nodes and in col- 
lections under the mucosa. On going 
back through the records of the hospi- 
tal Blumgart found two other similar 
cases. In retrospect these were all early 
examples of Whipple's disease. 

But for serendipity, Blumgart 
might well have specialized in disor- 
ders of salt and water, in endocrinol- 
ogy, or in gastroenterology. He was 
granted a Mosely Traveling 
Fellowship, however, to study in 
London for a year and arrived there in 
January of 1922. His intent was to 
attach himself to Sir Henry Dale, then 
a famous professor of pharmacology at 
the University of London, and to 
enroll in a course in physical chem- 
istry, medicine's premier basic science 
of the 1920s. 

He was too late to enroll for the 
course, however, and Dale's depart- 
ment was entirely caught up in the big 
academic-industrial joint effort of 
1922 — the search for a marketable 
insulin. Blumgart, who never really 
enjoyed bench chemistry, was unwill- 
ing to become another pair of hands 
extracting the pancreas. He spent a 
good deal of time in the library look- 
ing up the world's literature on nasal 
absorption and Dale let him do some 



experiments entirely on his own (as he 
emphasized in his letters to Drinker), 
in which he measured the absorption 
of various substances from the nose 
into the bloodstream. He tried squirt- 
ing insulin into the nose, but it was not 
absorbed. 

He was getting pretty tired of this 
when another happy accident occurred 
that was to definitively turn him into a 
cardiologist. In 1923 Sir Thomas 
Lewis was perhaps the most charis- 
matic, provocative and exciting cardi- 
ologist in Britain. He was doing all 
kinds of interesting things with the 
cumbersome but fascinating electro- 
cardiograph, describing circulatory 
reflexes, arrhythmias, syncope and 
abnormalities of the peripheral circula- 
tion. Blumgart fell under his spell and 
was immediately put to work measur- 
ing venous pressure at the bedside (by 
the same method we use today) in 
cases of paroxysmal tachycardia and 
other disorders of the heart. Work 
with Lewis on the wards of University 
College Hospital was so interesting 
that Blumgart, recently married to 
Ruth Mack, who was completing her 
medical education in Boston, turned 
down an offer from his father-in-law, 
Judge Julian Mack, to join him on an 
extended vacation jaunt throughout 
continental Europe. 

At the end of his fellowship, 
Blumgart didn't have a job to go back 
to, so in the fall of 1923 he wrote to 
Cecil Drinker inquiring about the pos- 
sibility of working with him in the 
physiology department or, as he pre- 
ferred, with Peabody at the Boston 
City Hospital. That golden boy of 
Harvard medicine had been made pro- 
fessor and chief of a new unit to be 
called the Thorndike Memorial 
Laboratory, located at Boston City 
Hospital. It was to be a place where 
clinical investigation could be carried 
out in the context of service to the 
poor of Boston. 

Because the laboratories were not 
yet ready, Peabody, back from the 
Peking Union Medical College, was 
still vacationing at his family home in 



Summer 1995 



4.^ 



Northeast Harbor, Maine, late in 
September 1923. Drinker wrote to 
Peabody indicating that his own 
department was absolutely full and 
although he wished he could make 
room for Blumgart, whom he liked, he 
saw no way to do it. "I wondered 
whether you would have any opportu- 
nit\" for him in January and whether 
you cared to take in another of the 
Chosen People. I feel sure that he is a 
man who will put things through. He 
is what I think of as the honest type of 
Hebrew — that is to say, he does not 
try to be anything else and does not 
want to be." 

Peabody wrote back that he was 
"not particularly worried about his 
race," but that of course he would have 
to look into the budget situation with 
the hospital director, John J. Dowling. 
He mentioned to Drinker that he had 
in mind to recruit Bill Castle as well. 
By January the budget arrangements 
had been made and Blumgart, age 28, 
was appointed as assistant resident 
physician at the Thorndike Memorial 
Laboratory at the salary of $400 per 
year. 

It was time for another gift of 
serendipity. That came in the form of 
a noninvasive way to study the velocity 
of blood flow — the circulation time. As 
a medical student in Cannon's labora- 
tory working with Peabody, Blumgart 
had tried a few desultory experiments 
to measure the velocity of blood flow 
from the vein of one arm to the artery 
of the other by injecting salts of 



hthium and strontium, but these 
experiments had been inconclusive. In 
1922, while in his lonely library period 
in London, Blumgart had read a paper 
in the German literature in which flu- 
orescein was injected as a marker sub- 
stance. This substance also posed 
technical difficulties and arterial punc- 
ture was necessary to get good results. 

The answer was radioactivity. 
Peabody had been physician-in-chief 
at the old Huntington Memorial 
Hospital, a cancer hospital, located on 
the present site of Countway Library. 
A common practice there was to treat 
malignancies by inserting radon seeds 
deep into them. After the radon 
decayed, a lot of radioactivity 
remained and had to be disposed of. 

Together with a physicist from MIT 
named Otto Jens and an engineer 
named Hewlett, Blumgart devised a 
painstaking way to precipitate radium 
from the seeds onto platinum elec- 
trodes, dissolve it in hydrochloric acid 
and then dilute it in a syringe so a 
small amount could be injected intra- 
venously. The amount of radioactivity 
(1-5 microcuries) was, they thought, 
negligible. Jens devised an elaborate 
cloud chamber as a detection device so 
that the passage of the injected 
radioactivity through the contralateral 
arm could be noted instantaneously 
and precisely, with the body shielded 
by a lead barrier. They used conven- 
tional stopwatches initially to deter- 
mine the mean normal arm-to-arm 
time — 18 seconds — and its variability 



Blumgart on graduation from HMS, age 26, in 1921. The permanent mailing address was that of his brother Leonard, 
then practicing psychiatry in New York City. 



n ,\ 



i'Wl 




in disease. In later studies they used 
what was essentially a Geiger counter 
as a detector with a constant source of 
voltage — some i ,000 small test tubes 
set up in a series on huge racks. These 
were the first published clinical studies 
using radioactive indicators. 

In 1925 Soma Weiss arrived and 
was assigned to work as Blumgart's fel- 
low and assistant. Together, they mea- 
sured the circulation time in almost 
every disease that presented itself on 
the teeming wards of the Boston City 
Hospital. They presented an abstract 
of their work at the 1925 meeting of 
the "Young Turks," the American 
Society for Clinical Investigation. 
(Also on the program was the first 
description of the electrolyte abnor- 
malities in gastric alkalosis by a young 
pediatrician ft-om Children's Hospital 
named James Gamble.) Peabody's 
name appears first on the abstract, 
most likely because he suggested the 
use of radioactivity. In later presenta- 
tions Peabody is thanked for his inter- 
est and his encouragement, but he is 
not listed as an author (an indication, 
possibly, of his generous style as chief). 

Publication of these interesting 
results was delayed for two years while 
data were accumulated. Then, between 
1927 and 1929, Blumgart and Weiss 
published 15 papers, followed in 193 1 
by a 7 5 -page review of the velocity of 
circulation appearing in Medicine. In 
1927 alone, this prolific duo published 
eight papers in the Journal of Clinical 
Investigation. All but one list the 
authors as Blumgart and Weiss. 

In 1928 the newly erected Beth 
Israel Hospital became affiliated with 
the Harvard Medical School. Harry 
Linenthal, its physician-in-chief, was 
highly respected in the Boston com- 
munity, but the hospital's trustees and 
the medical school wanted, in addi- 
tion, to identify a director of research, 
someone with a vigorous vision of 
research medicine, who would be 
chairman of a Harvard department and 
in charge of teaching Harvard stu- 
dents. Joseph Aub of the 
Massachusetts General Hospital was 



46 



Harvard Medical Alumni Bulletin 



first approached, but he turned down 
the post. Blumgart was the favorite 
both of Christian and Peabody; he had 
just dechned a lucrative job offer at the 
University of Chicago and he accepted 
the new post at Beth Israel immedi- 
ately. Until his retirement in 1962, 
Blumgart was the most influential per- 
son at the new Beth Israel Hospital. 

Ben Banks, who was a medical 
intern in 1930, has described the way 
rounds were conducted in the old days. 
They were very formal. Rounds always 
took place at the bedside with 
Blumgart on the patient's right and the 
student or intern on the patient's left. 
The head nurse stood at the patient's 
head, on the professor's side, to assist 
in readying the patient for a physical 
examination. The ward service con- 
sisted of 50 beds, 25 male and 25 
female; there were two open wards of 
20 beds each. 

Cases were presented at the bedside 
in five minutes maximum with no ref- 
erence to notes. Following the presen- 
tation, Blumgart did a pertinent 
physical, pointing out positive findings 
to the group. His practice then was to 
sit down on the bed and talk to the 
patient while others listened. He 
would often hold the patient's hand as 
he explained the nature of the illness, 
sometimes drawing a picture to make 
his explanation more clear. 

"Knowledge of the nature of the ill- 
ness and its expected course, explained 
in kindly and optimistic terms, is com- 
forting," he said to his students. 
"There is no condition so complex 
that it cannot be explained in simple, 
intelligible language." 

Blumgart brought to Beth Israel 
what was then thought of as the 
Brigham system for interns on call. 
Interns were expected to sleep in the 
hospital. It was not an easy life. With 
an economic depression looming, the 
hospital director, worried about the 
bottom line, made things more diffi- 
cult. Lights were turned out in the 
dining room after 1 1 :oo so that the 
interns wouldn't eat too much and 
attendants kept watch lest they take 





Soma Weiss (left) and Herrman Blumgart In their laboratory at the Thorndike. 



more than one scoop of ice cream. 

A few months into the internship, 
according to Banks, some of the house 
staff felt that perhaps the rules were a 
little too rigid and decided to discuss 
this with Blumgart. Some more radical 
souls talked briefly of getting up a 
petition, but this dangerous idea was 
dismissed by the majority. The next 
morning there was an emergency call. 
All house staff were to report immedi- 
ately to Blumgart's office. They 
arrived to see him looking very grim. 
Evidently word of the dining room 
conversation had been leaked to the 
chief "If anyone doesn't like it here, 
they can pack up and get out right 
now!" he said. No one did and they all 
filed out sheepishly. 

As head of the Harvard 
Department of Medicine at Beth 
Israel, Blumgart approached his teach- 
ing responsibilities with great serious- 
ness. He was a gifted and impressive 
teacher, though he confessed to a 
friend that he never got over being 
nervous before a lecture. At Walter B. 
Cannon's suggestion, he initiated a 
course on the physiological basis of 
disease, which was always oversub- 
scribed. He also gave the introductory 
clinic for fi"eshman medical students 
for many years, using his own patients. 



A favorite subject was a patient with 
heart block, permitting him and Paul 
Zoll '36 to explain the dramatic and 
life-saving results of using the pace- 
maker that Zoll had developed at Beth 
Israel Hospital. 

Blumgart is described by his con- 
temporaries as reserved, always com- 
posed, with a dignity that could be icy; 
he was soft-spoken but enormously 
tenacious. He was generous in many 
ways, but it was never easy for a mem- 
ber of the staff to challenge him in 
public. There is a biography of Henry 
Ford entitled, IVe Never Called Him 
Henry. At Beth Israel Hospital, they 
never called him Herrman. To this day 
his residents and former faculty, now 
in their 70s and 80s, find it difficult to 
refer to Blumgart by his first name. 

It was very important to him, how- 
ever, that his proteges, students and 
house officers, succeed. He furthered 
their careers in every way he could, 
interceding personally time and again 
to make sure they got training in the 
very best laboratories or clinics avail- 
able for their particular specialties at 
other institutions. He was loyal to 
them and he retained their loyalty 
throughout their lives. 

His iron self-control served him 
well in the numerous unavoidable 



Summer 1995 



47 



w % 




Early Geiger counter used to detect radioactivity in the measurement of circulation time. 



arguments with other chiefs or with 
the hospital administration. The story 
goes that when Jack Fine, the brilhant 
but volatile chief of surgery would 
come to Blumgart's office to discuss a 
point at issue, Fine's voice would be 
heard louder and louder from behind 
the closed door while Blumgart's got 
softer and softer. Then the door would 
be flung open and Fine would stalk 
out. Blumgart had won his point. 

He managed to get the hospital 
administration's approval for a small 
salary to be allotted to an assistant 
librarian who would work in the small 
hospital library in the evening. This 
position was reserved for an impover- 
ished Harvard medical student who, by 
virtue of the appointment, could have 
free meals at the hospital. Irving 
London '43A and Bernard Davis '40 
were two former medical students, 
later eminent leaders in American 
medicine, who benefited from this 
thoughtfulness. 

Blumgart's early interest in psychi- 
atry and in the mental origins of illness 
never left him. This was partly due to 
his brother Leonard's influence and 
partly to the intellectual temper of the 
times. 

An aftermath of every war, it seems, 
is the rediscovery of the importance of 



mental illness. During World War I, 
Blumgart's mentor, Francis Peabody, 
had been in charge of a ward of sol- 
diers with "irritable heart," or circula- 
tory neurasthenia. Peabody, whose 
approach and style were consciously 
copied by his protege, became 
intensely interested in the role of emo- 
tions in illness and was a good friend 
of Morton Prince, the Harvard and 
Tufts professor of psychology, who 
wrote popular books about split per- 
sonalities. Blumgart's first wife, Ruth 
Mack Brunswick, was analyzed by 
Freud and became a noted psychoana- 
lyst herself. And Blumgart was later 
responsible for the recruitment to 
Beth Israel of Grete Bibring and her 
husband, Edward, who founded a cen- 
ter for psychoanalytic study. 
Blumgart's George Washington Gay 
Lecture in 1963, entitled "Caring for 
the Patient," has a contemporary 
sound in the way he acknowledges the 
role of emotions in illness: 

"If you increase your skill and 
regard to dealing with the patient as a 
human being with problems and diffi- 
culties, and understand the inter-rela- 
tionship between that person and his 
disease, you will become better diag- 
nosticians, and what is more important 
better physicians. ... Illness brings 



many moments of vast loneliness, none 
more difficult than the long journey 
on a flat, hard uncomfortable stretcher 
from the ward to the operating the- 
ater. Never have I known patients 
more appreciative of a familiar figure 
than during that anxious trek and dur- 
ing those moments as they lose con- 
sciousness." 

Blumgart's later research interests 
included the possibility of treating 
heart disease by reducing thyroid func- 
tion, a concept now outmoded. But 
important in the light of later develop- 
ments was a detailed and ground- 
breaking study of the functional 
anatomy of the coronary circulation, 
carried out with Monroe Schlesinger 
of the Department of Pathology, and 
with ZoU and Al Freedberg, which is 
the basis for the current treatment of 
coronary heart disease with bj/pass and 
angioplasty. Blumgart was also editor 
of the journal Circulation for 10 years. 

There was another unexpected, 
interesting accidental footnote to 
Blumgart's story, if not so serendipi- 
tous. In the early 1940s a young Czech 
refugee physician, who was visiting the 
teaching wards at Beth Israel Hospital, 
brought the news that a German resi- 
dent in urology named Werner 
Forssman had succeeded in catheteriz- 
ing his own heart with a ureteral 
catheter. Mixed venous blood could 
thus be obtained and accurate cardiac 
outputs measured for the first time by 
application of the Fick method. 
Freedberg proposed to Blumgart that 
such studies be initiated at Beth Israel 
Hospital. 

It must have been very tempting to 
someone who had studied with 
Drinker and Lewis and who had 
invented the first practical method of 
measuring circulation time to get in on 
what promised to be a new technique, 
which would open up vast areas of 
investigation in clinical cardiology. But 
caution prevailed. Putting a foreign 
body right into the heart seemed like 
an awfully dangerous thing to do. One 
life lost in needless experimentation 
would blacken the name of the depart- 



48 



Harvard Medical Alumni Bulletin 



ment that he had raised and cherished 
for a long time. "If we have an acci- 
dent," he said to Freedberg, "the hos- 
pital will go down the drain." 

Andre Cournand and Dickinson 
Richards eventually won the Nobel 
Prize in Medicine (shared with 
Forssman) for their studies with the 
cardiac catheter at New York's 
Bellevue Hospital. Cardiac catheteri- 
zation did not come into its own at 
Beth Israel Hospital until some 35 
years later. In retrospect it was perhaps 
the greatest mistake of Blumgart's dis- 
tinguished career. 

In 1962, at the age of 67, Blumgart 
retired and was succeeded by his bril- 
liant young protege, Howard Hiatt 
'48. Blumgart continued to teach and 
was an influential member of the 
Admissions Committee for Harvard 
Medical School. He always spoke last 
at committee meetings, quietly but 
with tremendous effect. Not infre- 
quently he took the unpopular view of 
supporting the brilliant but unstable 
candidate in whom the possible reward 
might outweigh the recognized risk. 

After I was offered the position of 
physician-in-chief at Beth Israel 
Hospital in 1972, as Hiatt's successor, 
I visited Blumgart to talk about it. He 
had an impressive quahty of kindness 
and warmth, combined with an eagle- 
like dignity. His appearance had hardly 
changed since his pictures taken at the 
opening of the Thorndike Memorial 
Laboratory when he was barely 3 0; his 
hair was still black, his Harvard accent 
impeccable. He told me how he had 
always tried to emphasize the strengths 
of this relatively small hospital in the 
Harvard system, develop its contribu- 
tion to teaching and to recruit young 
men in areas not covered by other hos- 
pitals. He told me that he thought I 
would like the Beth Israel and would 
learn from it and he urged me to 
come. He told me to get everything in 
writing. He was right on every count. 

In the last few years of his life he 
fell victim to a succession of vascular 
events: two heart attacks and a stroke 
that left him without the power of 



speech. Laboriously, with immense 
resolve, he gradually regained the abil- 
ity to form words and sentences and to 
communicate with his friends and fam- 
ily again. 

In 1977, at the age of 82, he devel- 
oped a carcinoma of the colon, which 
William Silen removed at Beth Israel 
Hospital. He was sent to the Stillman 
Infirmary to recuperate. There one 
evening, after his daughter Ann had 
said goodnight and left, he wandered 
around the hall in his bathrobe. He 
stopped by the bed of a young Harvard 
College undergraduate, hospitalized 
with infectious mononucleosis. The 
young man was terribly scared because 
he thought he had leukemia and was 
certain he was going to die. 

Blumgart introduced himself, sat 
down on the bed and took his hand. 
He slowly but clearly explained the 
nature of the benign illness. As he 
spoke, the words came more easily, 
with the old sureness. He drew the 
student a picture, told him that it was 
understandable to be upset, but that he 
was going to get well. The student 
grew calm and was finally able to 
sleep. Later that night, Herrman 
Ludwig Blumgart died. 

That was the final and wonderful 
gift of serendipity. It must have been 
the happiest of accidents to be able to 



Herrman Blumgart (center) with Paul Zoll (left) and A. Stone Freedbei^, about 1950. 



feel again the magical power of the 
white coat, the pleasure of speaking 
words that soothed and relieved and 
healed — to experience once more the 
secret joy of being a physician. 

He stood, in his time, for a mixture 
of rigorous honesty, scientific excel- 
lence and human compassion. He 
would surely be pleased to see how, 65 
years later, the enterprise he started 
has flowered and the qualities of intel- 
ligence and compassion that marked 
his life shine in the institution that he 
helped to build. '^ 

Franklhi H. Epstein is William 
Applebauin Professor of Medicine at 
Harvard Medical School and the Beth 
Israel Hospital Department of Medicine. 
He was Hemnaji Blumgart Professor of 
Medicine and physician-in-chief fi^om 
1 973-1 980. This is adapted from an 
after-di?mer talk to the Department of 
Medicine, Beth Israel Hospital, at the 
Harvard Chib of Boston on March 1 8, 
1993. 




f / 




' •TTifciillMFiii "nr' 



' X- .'W^mfL^rSK^JK^i'^ 



«4 



Summer 1995 



49 







■f f>' 



The Physician-Scientist: 



Dual or Dueling 



by David A. Shaywitz 



5° 



Harvard Medical Alumni Bulletin 




photo by Stuart Darsch 



Degrees: 



P 



Summer 1995 



51 



"Sometimes I pinch myself^Pm doif7g 
what I've always wanted to do. Two of the 
things that make you feel best are making 
discoveries in lab and working with fami- 
lies of sick children. I get to do both. " — 
Michael Kastan, MD/pHd, Department 
of Pediatric Oncology, Johns Hopkins 
University. 

"Both science and medicine are so 
demanding — it is impossible to do both 
well. I thifik it is becoming iiicreasingly 
clear that you have to do one or the other. 
It is important to collaborate closely. I 
think that physicians should tmderstatid 
science well enough to communicate with 
the scientists, for example, but I don V 
think they need to do PCR, etc. Similarly, I 
don V think that scientists need to draw 
blood and lay on hands. " — David 
Botstein, PhD, professor and chair of 
genetics, Stanford University. 

For many of us, the MD/phD repre- 
sents an elegant sjmthesis of two great 
passions — a love for the practice of sci- 
ence and a love for the art of healing. 
Fundamentally, the dream many of us 
share is to be able to elucidate an 
essential biological process and then 
apply this knowledge to the care and 
treatment of patients. This idea of 
conducting first-class basic research 
while maintaining a meaningful clini- 
cal interaction is extremely appealing 
and speaks of a synergy that, in many 
ways, is the organizing principle of the 
MD/phD program. Although some of 
the nation's best contemporary scien- 
tists and physician-scientists support 
this paradigm, however, many others 
feel that it represents an unrealistic — 
and in some ways counterproductive — 
ideal. 

Can one do first-class research and 
be an excellent chnician? "No," 
answers MIT cancer biologist Robert 
Weinberg. "It is a destructive myth on 
which American academic medicine 
operates because it encourages people 
to try something that is impossible to 
accomplish. Many people have excel- 
lent clinical skills and maintain a cha- 
rade of meaningful research, but it is 



For many ofus^ the 
MD/phD represents 
an elegant synthesis 
of two great passions. 



just that — a charade — and one which 
represents an enormous waste of 
resources. I can count on one hand the 
people who are doing excellent science 
and maintaining a foot in the clinical 
door; it just is not possible. Each of the 
two, individually, is too demanding." 

Yet others assert that the career 
model of a physician-scientist is still 
quite viable. "It has evolved," says 
Judah Folkman '57, a pediatric sur- 
geon at Children's Hospital who pio- 
neered the study of angiogenesis, "into 
an array of different types of careers 
having many degrees of freedom and 
gradations. Where are the role models 
for the next generation of physician- 
scientists? They are all over the place, 
and each has arranged his or her own 
personalized mix of patient care and 
research, sometimes in a sequential 
fashion, sometimes side by side. And 
they are having more fun than they 
want to let on." 

Not only is the integration of basic 
science and clinical medicine possible, 
say some researchers, but it is also nec- 
essary. "Given today's technology and 
knowledge, there is a need for people 
who understand medicine to be 
involved in research," observes devel- 
opmental biologist H. Robert Horvitz, 
who maintains one lab at MIT and is 
involved in a major collaborative effort 
at the MGH. "There are medical prob- 
lems that, for the first time, are 
tractable scientifically." 

Adds Harvard transplantation sur- 
geon Joseph Murray '43B, "It is 
absolutely necessary that clinicians be 
basic scientists, because basic scientists 
will never be clinicians. When you 



take care of patients, you get exposed 
to problems that are compelling, prob- 
lems that are worth pursuing in the 
lab." 

Critics of the dual-career track, 
however, such as Stanford biochemist 
(and MD) Arthur Kornberg, contend 
that "doing clinical medicine prop- 
erly — looking after patients in a mean- 
ingful way, keeping up with important 
advances, etc. — has a major negative 
effect on research." 

Who is right? Is it possible to com- 
bine basic research and clinical medi- 
cine in a career and if yes, then to what 
extent? Does the physician-scientist 
emerge from the long training as a 
"superdoctor," equally comfortable at 
the bench or the bedside, or as an 
over-educated, over-committed and 
overwhelmed thirtysomething who is, 
in the words of Weinberg, "a jack of 
all trades, but a master of none?" 
These are very difficult questions for 
us to ask about ourselves, but ones that 
every MD/phD will and must confront. 

The Medical Scientist Training 
Program was initiated in 1964 as part 
of an effort from the National 
Institutes of Health to create a cohort 
of individuals who might bridge a per- 
ceived gap between bench researchers 
and clinicians. Currently, the MSTP 
grant funds MD/phD programs at 3 2 
universities and supports approxi- 
mately 800 students; a number of stu- 
dents also pursue both degrees without 
MSTP funding. For MSTP students 
nationally, the average time required 
to obtain the combined degree is 
approximately seven years; the average 
at Harvard is closer to eight years, 
with training periods of nine and ten 
years not unheard of. 

Though long, the MSTP is also very 
popular: last year nearly 300 students 
applied for one of Harvard's five first- 
year positions. For students committed 
to clinical medicine, the program pro- 
vides an opportunity to develop a 
grounding in basic science. Even if 
they don't pursue basic research, they 
can still follow it and perhaps more 
easily anticipate where advances might 



52 



Harvard Medical Alumni Bulletin 



have important clinical implications. 

For students more interested in 
bench research, the program provides 
an opportunity to develop a familiarity 
with clinical issues, which might both 
inform their direction of research as 
well as suggest areas where a clinical 
implication might be pursued. Finally, 
for students interested in working in 
both realms, the program provides the 
basic education and vocabulary 
required to understand the needs and 
the resources of both the lab and the 
clinic. Traditionally, the first group of 
students moves on to become "acade- 
mic physicians," the second group, 
"basic scientists" and the third group, 
"physician-scientists . " 

When the combined degree pro- 
gram first started, it was greeted with 
some skepticism by clinical faculties. 
"They took awhile to come around," 
says Lee vanLenten, director of the 
National Institute of General Medical 
Science, the NIH division that oversees 
the MSTP program. "Their concern 
was that for the combined degree stu- 
dents, the PhD was the primary moti- 
vation and the MD was second — that 
these students couldn't be well-trained 
clinically because they weren't inter- 
ested." Currently, however, this con- 
cern seems to have dissipated; MD/pho 
students compete quite successfully for 
both residencies and medical school 
faculty appointments. 

Some bench scientists are also 
enthusiastic about the combined 
degree program. "The future is with 
the MD/pho students," says University 
of Washington geneticist Leland 
Hartwell. "They'll make a difference 
in lo years. It is a very demanding, 
very anxiety-ridden route, but having a 
real medical training and then doing a 
rigorous PhD is a truly valuable and 
worthwhile investment." 

Not all bench scientists share this 
perspective, however. Many feel that a 
career in basic science is, in general, 
incompatible with almost any clinical 
responsibilities. They argue that it's 
fine if someone wants to apply 
advances in basic research to problems 



"Many people have 
excellent clinical 
skills and maintain 
a charade of 
fneaningful research^ 
but it is just that — a 
charade. " 

Robert Weinberg 



in the clinic, but they believe that 
while this research may be good and it 
may be important, it is not basic 
research. For people with dual training 
to devote themselves to basic research, 
with no clinical responsibilities, may 
also be reasonable, since the cost in 
time of the additional training may be 
balanced by the clinical perspective it 
affords. MD/pho graduates can expect 
disappointment, however, if they plan 
to combine basic research with a clini- 
cal interaction. Today's basic research, 
the reasoning continues, is too 
demanding to combine with anything 
else, and clinical medicine detracts 
from basic research rather than com- 
plementing it. 

In essence, the major arguments 
against conducting basic research 
while maintaining a clinical interaction 
are: (i) the long training period 
detracts ft-om optimal research time; 
(2) bench research requires absolute 
focus; (3) no one can maintain two dif- 
ferent careers; (4) clinical medicine 
and bench science are fundamentally 
different and are not mutually rein- 
forcing. 

The Long and Winding Road 
The long training period required for 
MD/phDs represents, to many 



researchers, the most significant 
potential pitfall for MD/phD students. 
Marjorie Oettinger, a biologist at the 
MGH, began in the Harvard/MIT 
MD/phD program but departed after 
completing the PhD to start her own 
lab: "I started out quite sure I wanted 
to and could do both; it seems less easy 
now. At 20, you're sure that you'll be 
awesome, that you'll have an infinite 
amount of time and skill, and that you 
will push your career as much as possi- 
ble. Along the way — as you do 
research seven days a week, sixteen 
hours a day, and it's still going 
slowly — you realize that you'd also like 
to have kids and that you'd also like to 
do medicine, and you start counting 
the years." 

"My major concern about the 
MD/phD program is the time it takes," 
agrees MIT biologist Phillip Sharp, 
whose lab has trained many MD/phD 
students. "I don't like the idea that 
people emerge ready to do mature sci- 
ence at age 35 and not at 27 or 28. 
The most scientifically productive 
years are immediately after training, 
while you're developing as a young 
person with energy, intensity. If you 
displace out to 35, you have older fam- 
ilies, greater responsibility. If that's the 
first time you're scientifically indepen- 
dent, it's late." 

MIT biologist David Baltimore 
expresses similar feelings: "I think peo- 
ple should make the decision when 
they graduate from college," he says. 
"I think it's fine to choose an MD/pho 
program if you decide you truly need 
both kinds of education, but I think 
that most people enter the program 
because they are avoiding the decision. 
In avoiding the decision, they are 
wasting the best years of research life." 

The real issue, many believe, isn't 
that MD/phDs run out of time, but 
rather that since they start their 
careers when they're older, they tend 
to want to be established too quickly. 
Thus they tend to do more superficial 
research, rather than truly investing 
themselves in an important problem. 
"They're less likely to take the long- 



SuMMER 1995 



53 



term perspective," says Baltimore. "In 
a sense, tiieir desire is too burning." 

Alanv physician-scientists, however, 
counter that the time issue is too often 
exaggerated. "When I apphed to med- 
ical school," MGH neurologist/neuro- 
scientist Anne Young relates, "die 
Harvard recruiters told me they didn't 
believe in MD/phD programs because 
they take much too long. Well, I went 
to Johns Hopkins and was on the fac- 
ulty by 30, had my first grant at 30 and 
had published 40 papers by 33. You 
can find MD/PhDs who are productive 
early on." 

"It is a long road, but you get a 
unique perspective," observes Arlene 
Sharpe '82, a member of the HMS 
pathology department who runs the 
core transgenic facility at the Brigham 
and Women's Hospital. "Although 
most MD/PhDs don't reach indepen- 
dence until their mid 30s, I found that 
doing both taught me how to juggle." 

A Need to Focus 
To many scientists, a career of basic 
research requires absolute focus with- 
out the "distractions" that clinical 
medicine represents. "If you want to 
be successful in basic science," 
explained the late chemist Linus 
Pauling — who in 1 949 first coined the 
term molecular disease — "you proba- 
bly have to devote all your time, all 
your thinking to it. You can't do this if 
you have patients — the primary 
responsibihty of physicians is to take 
care of patients. If you want to dis- 
cover the double helix, you can't do it 
while practicing clinical medicine." 

Yet, many physician-scientists 
worry that by maintaining a restrictive 
focus, many bench researchers fail to 
appreciate the larger picture. 

"Big discoveries are serendipitous 
and you need to get the big picture to 
advance the way we think," argues 
Michael Kastan, a pediatric oncologist 
at Johns Hopkins University who stud- 
ies the P53 gene. "In graduate school, I 
thought that the questions we were 
asking in the lab were the most impor- 
tant things there were. I've since real- 



ized that it's not optimal for me to 
approach science that way; in addition 
to being good at the details, as a prin- 
cipal investigator you need to know 
how your work fits into the big picture 
so you can ask big-picture questions. 
This is the biggest advantage of clini- 
cal work." 

Children's Hospital pediatric 
hematologist Stuart Orkin '71, a 
physician-scientist who attends on the 
wards one month a year, feels that 
although in practice, the bedside rarely 
informs the bench, and although he 
has received "very limited insight from 
the wards," the MD/phos nevertheless 
possess a perspective that is different. 
Orkin says that in his lab, the post- 
docs with MD/phos "seem, in general, 
to be intellectually more mature, to 
have a more global sense of biology, of 
where things fit, but they may be less 
equipped to do the actual experiment. 
By contrast, the Phos are often better 
able to do the experiment, but they are 
less able to formulate how it fits in." 

"It's a trade-off," explains Harvard 
geneticist Philip Leder '60. "Clinical 
involvement takes time from full-time 
research but it provides insight into 
nature and a broad view of human 
biology and pathology." 

Dual Training vs. Dual Career 
Many scientists — and particularly, 
many physician-cum-scientists — con- 
sider the clinical training useful but 
the combined career unrealistic. Says 
Stanford geneticist David Botstein: "I 
think it's reasonable to obtain both 
educations, but not to pursue both 
careers." 

Joseph Goldstein, who chairs the 
Department of Molecular Genetics at 
University of Texas-Southwest and 
who is often cited as a model physi- 
cian-scientist, says "It's harder and 
harder for someone to do both. 
Science is a tough world and things 
move very fast. You can do 10 to 20 
times more now than what you could 
20 years ago. To be competitive at the 
forefront of science, you must spend 
95 percent of your time thinking about 



''If you want to 
discover the double 
helix, you can V do it 
while practicing 
clinical medicine. " 

Linus Pauling 



it and doing it. If you want to do cut- 
ting edge research, it will be almost 
impossible to be responsive to patients 
who call you up." 

Don Ganem '76, an infectious dis- 
ease specialist at University of 
California San Francisco (UCSF) whose 
research focuses on the mechanism of 
reverse transcriptase action in hepatitis 
B, acknowledges that he has had to 
make compromises in order to com- 
pete with those doing research 100 
percent of the time. He says, however, 
"if you're well trained, you can still 
function at a high level in your field. 
It's possible to stay well read in areas 
that are important to your daily work, 
but it's harder to stay up on things fur- 
ther afield; I just can't do primary 
reading in these areas. Similarly, I find 
that in medicine, I must concentrate 
on things directiy affecting my spe- 
cialty." 

Robert Glickman '64, chair of med- 
icine at the Beth Israel Hospital, 
asserts that "doing both is possible 
under very discrete circumstances. You 
need a support system. I think you 
must set the clear, clear, clear expecta- 
tion that you'll spend the dominant 
part of time doing research. Focus on a 
concentrated area, and don't get 
diverted." 

Doing both science and medicine 
well "is possible in certain fields, less 
achievable in others," agrees Stuart 
Lipton, a neurologist and neurobiolo- 
gist at Harvard Medical School. "It 
would be very difficult in neuro- 
surgery, for example; if you're choos- 



54 



Harvard Medical Alumni Bulletin 



ing a surgeon, you want one who oper- 
ates at least every other day. In medi- 
cine, while you need an intense initial 
training, it is not necessary to be in 
clinic every day." 

An Elusive Synergy 
One of the most persistent critiques 
made by basic researchers centers on 
the idea of cross-fertilization between 
the lab and the clinic. "The idea that 
basic science and clinical medicine are 
complementary is naive," says MIT 
cancer biologist Tyler Jacks, who was 
(briefly) a member of UCSF's MD/pho 
program before deciding on a career of 
full-time research. "The bench and the 
bedside involve radically different 
things. The kinds of skills you need on 
the wards don't apply to the study of 
the cancer cells in the tissue-culture 
dish, for instance. There are examples 
where careers were launched by iden- 
tifying a problem in disease and 
approaching it from the molecular or 
cellular point of view. But crosstalk 
once you've made the decision to pur- 
sue basic science? I think not." 

This synergy "rarely materializes" 
agrees Baltimore, adding: "There is a 
real dissociation between science and 
medicine; the work occurs at a differ- 
ent level. Medicine is the solution of 
pressing problems with insufficient 
information, and science is more or 
less the opposite; you have the time to 
get the information." 

"Some people have active labs as 
well as clinical responsibility," 
observes Jacks. "They do it because 
they enjoy it, because they get satisfac- 
tion from it; in general, they don't do 
it because the kinds of information 
they receive directly benefits their 
research. However, there is a sacrifice 
involved in maintaining the clinical 
work." 

Unquestionably, many MD/phos 
find unique fulfillment in combining 
both strands of their careers. 

"The idea of going from bench to 
bedside and bedside to bench came 
from an era before molecular biology, 
the era of metabolic studies," NIH 



Deputy Director Ruth Kirkstein 
explains. "Now, doing molecular biol- 
ogy doesn't require you to be two feet 
from the patient. Your clinical experi- 
ence, however, still gives you an 
improved understanding of the 
patient's disease and of the basic 
processes that underlie it." 

Anne Young also cites the need for 
an interface: "For example, you can 
find protein processing pathways for 
intracellular signalling systems but you 
need to ask, what is its relevance? You 
must have insight into human disease 
to know how to ask the questions." 

Alternative Approaches 
While the MD/pho program represents 
one approach towards bridging the gap 
between clinical medicine and bench 
research, it is not the only option. For 
example. National Institutes of Health 
(nih) Director Harold Varmus "would 
like to see more diversity in the kinds 
of programs we offer students; for 
example, Pho programs with more 
clinical material." Such programs have 
already been initiated at Harvard and 
UCSF, as well at several other medical 
centers around the country. 

The Harvard-Markey Biomedical 
Scientist Program "represents an effort 
to broaden the training to the 
MD/pho," according to its director, H. 
Franklin Bunn. Graduate students in 
this program devote a full year to the 
study of human biology, receive clini- 
cal exposure, and are also invited to 
become members of the medical 
school's five academic societies. 

Another approach towards bridging 
biology and medicine, developed and 
implemented by University of 
Washington biologist Leland 
Hartwell, involves weekly human 
genetics seminars that aim to "encour- 
age graduate students in basic research 
to think about cHnical implications, to 
think about the connections between 
science and medicine." 

Implications 

The dramatic changes experienced by 

biology during the last 25 years repre- 



''The idea of going 
from bench to bedside 
and bedside to bench 
camefroTn an era 
before molecular 
biology^ the era of 
metabolic studies. " 



Ruth Kirkstein 



sent both a challenge and an opportu- 
nity for today's physician-scientist. At 
first blush, the direction much of basic 
science has taken might seem to repre- 
sent a barrier to the physician-scientist 
or, at best, a distraction: worms don't 
look much like people, yeast don't get 
cancer, and it is sometimes not imme- 
diately obvious that months of sorting 
through fly mutants or microinjecting 
xenopus embryos is going to lead to 
incisive clinical inferences. On the 
other hand, the molecular study of 
model organisms has allowed us to 
increasingly appreciate what Hartwell 
has termed the "unity of life." Genes 
involved in processes from cj^oskele- 
ton organization and secretion to cell- 
cycle regulation and apoptosis have 
been exquisitely conserved. 

To the extent that scientists and 
physician-scientists agree on the utility 
of model systems, the distinction 
between "basic" and "applied" 
research can become extremely grey; is 
the study of the role of the ALS gene in 
worms basic or applied? What about 
the study of the P53 gene in transgenic 
mice? Indeed, as the study of disease 
increasingly focuses on the examina- 
tion of specific genes, and as the study 
of fundamental cellular processes 
increasingly turns up genes implicated 
in disease, the targets for both the sci- 
entist and the physician-scientist have 
become^ in many cases, substantially 



Summer 1995 



55 



At a certain levels 
both the questions we 
all ask as well as the 
approaches we all 
take are essentially 
the same. 



the same. 

Does the argument that basic 
research and disease research are mov- 
ing closer together define or obviate 
the role of the physician-scientists? 
Why not just encourage MDs and Phos 
to work closely with each other? An 
answer, perhaps, is that MDs and PhDs 
still speak very different languages, and 
often conceptualize problems quite 
differently. Physician-scientists, having 
trained rigorously both at the bench 
and in the clinic, can help clinicians 
and scientists to understand each 
other's perspective, and to formulate 
questions in a manner meaningful to 
the other group. But even more 
importantly, MD/phDs offer what 
might be described as a unity of vision. 
Uniquely, they have the opportunity 
to identify an important biological 
question in the clinic, the means to 
pursue an intellectually satisfying 
answer in the lab, and the motive to 
bring an enhanced therapeutic per- 
spective back to the clinic. 

In the long view, the hope is that 
the combined-degree training, as well 
as alternatives such as the PhD track 
suggested by Varmus (and exemplified 
by the Markey Program), and courses 
such as the graduate class in human 
genetics initiated by Hartwell, will not 
just provide the basis for productive 
collaboration, but will also allow us to 
better understand natural systems — 
whether the protein is from aplysia or 
a primate, whether the vesicle is in a 



nematode cell or an islet cell, whether 
the goal is to understand yeast or to 
treat patients. The point is, at a certain 
level, both the questions we all ask as 
well as the approaches we all take are 
essentially the same. 

And finally, for MD/pho students in 
the midst of their training, it seems 
meaningful to note that nearly all the 
physician-scientists interviewed for 
this article felt that their own experi- 
ences were somehow idiosyncratic or 
atypical: "I didn't follow the usual 
route" or "I'm a special case" or (most 
frequently) "I was really lucky." If 
there is a designated route to becom- 
ing "a successful physician-scientist," 
there aren't many people who follow 
it. This responsibility to carve our own 
paths, while perhaps somewhat intimi- 
dating, is also empowering; it suggests 
that we have the real opportunity to 
help define for ourselves — and for our 
generation — what it means to be a 
physician, what it means to be a scien- 
tist and, perhaps, what it means to be 
both. ^ 

David Shaywitz, a sixth-year MD/PhD 
student, studies protein sorting in the labo- 
ratory of Chris Kaiser, Department of 
Biology, MIT. The contributions of Linda 
Burnley and Molly Lanzarotta to this 
article are gi'atefidly acknowledged. 



56 



HARVARD Medical Alumni Bulletin 



Seventh Shift 



by Charles C. Hartness 



The cardiac arrest was routine. The doctor took the 
radio call when the ambulance was five minutes out. There 
may have been an added sense of urgency to the paramedic's 
voice as she delivered the prehospital report over the radio, 
but the doctor did not detect it. He had worked 1 2 hours in 
the emergency department each of the last six days and after 
tonight he was off for five. 

The patient arrived. He was 64, and looked fit with a full 
head of white hair, and thick muscles beneath the tanned 
skin of his bare chest. One paramedic squeezed oxygen from 
an ambu bag through an endotracheal tube into the man's 
lungs. Another performed chest compressions. The patient 
had no risk factors for heart disease, but he was nevertheless 
dead. The doctor had nothing to add to the paramedics' 
care. "Okay, I think we can stop." He glanced up at the wall 
clock. "Time of death is 19:46." 

As he walked from the resuscitation room, the ward clerk 
told him the man's family was in the quiet room. Six new 
charts stood in the to-be-seen rack. This shift was off to a 
bad start. He passed the registration desk on the way to the 
quiet room and grabbed a gummed label with the man's 
name on it and stuck it to his left palm for easy reference. It 
is poor form to forget the name of the dearly departed as 
one introduces oneself to the next of kin. 

The quiet room was down a long hallway that attached 
the new emergency room annex to the old hospital building. 
As he walked toward the room, he glanced at the sticker in 
his palm. Walter Egan. DOB 06-22-30. His father's age. He 
imagined the people waiting for him in the quiet room. 
Perhaps a family something like his own. A sweet, short, 
plump aging widow. Two or three children in their 30s, 
with their respective spouses and perhaps a grandchild or 
two. One of the children will serve as the spokesperson for 
the group. For some reason it's always the child, never the 
widow, who asks the questions. 

The door was ajar. The doctor paused before he reached 
it, took a relaxing breath and stepped into the doorway. The 
room was occupied by a young woman, one of the daugh- 
ters he supposed. She looked about 30, and was strikingly 
beautiful, with thick wavy auburn hair and pale lightly 
freckled skin. She wore a printed sundress of daisies on an 
indigo background. On her feet were yellow canvas thongs. 
She held a tiny baby cradled in her arms, wrapped in a thin 
blanket. Its head was covered with fine red hair, of a 
brighter shade than the mother's. The left shoulder strap of 
the woman's dress dangled at her elbow and the baby was 



busily nursing at her freckled breast. 

She was so attentive to her baby, she did not see the doc- 
tor at first. When she did, she looked up at him with her 
angelic face, a mother's face full of hope. Hope that what 
she already knew would not be true. Hope that he would 
tell her it was all a mistake, a mere fainting spell, requiring 
only a few tests and a day in the hospital to make things 
right again. 

"Doctor?" 

He nodded. "Are you with Mr. Egan?" 

"Yes, I am his wife." 

Wife? Not daughter? 

The moment of truth was upon them. The doctor 
wanted someone else in the room with them before he said 
what he had to say. "Is there no one else here with you?" 

"No, we have no other family here. We are originally 
from back East." 

"I see." The doctor tried not to look at her breast as he 
sat on the sofa beside her. He reached out and lightly laid 
the fingers of his left hand against the skin of her right fore- 
arm. "Mrs. Egan, I am so sorry to have to tell you this, but 
your husband has died." He wanted to continue. He had 
done this a hundred times before but he suddenly did not 
know what to say. This woman, this widow, was too young, 
too lovely, too alone to be hearing these words. 

She looked at him. Her exposed breast heaved as she 
drew a ragged breath. Her baby continued to feed. She 
looked down at the baby, then back at the doctor. "I scolded 
him. I scolded him for not helping me bring the groceries 
in. I left them in the car to make a point. He finally went 
out to the garage. When he didn't come right back in, I 
assumed he was angry with me, so I didn't go out to check 
on him for a while. He was — he had fallen to the floor as he 
pulled one of the sacks from the back seat. It was the sack 
with delicate items, and I found him lying in a puddle of 
juice and eggs and milk. He is my husband and I shamed 
him into carrying the groceries." 

She began to cry, quietly. They sat in silence. He 
watched as the baby nursed. Overhead a belt cried against a 
pulley as a ventilation fan cycled on. The doctor and the 
woman looked up together at the louvered duct in the ceil- 
ing. The keening of the belt was the only sound in the 
room, and it died away as the fan came up to speed. ^ 

Charles C. Haitness '82 is an e?7iergency physician and paramedic 
advisor in Portland, Oregoji. 



Summer 1995 



57